Update: Any chance of appealing Medicare denial of CPAP?

[kaiasgram]

Hubby is 3 weeks post heart attack and we just found out that the sleep test he completed last month for Medicare showed an AHI of 4.3. He's been using CPAP since 2011 when he was diagnosed and we know he needs it. Pulmonologist assures us that Medicare will deny the new CPAP machine because his AHI was below 5 (we understand this to be accurate), so she doesn't want to go any further with trying to submit a prescription for him.

Another option is to repeat the sleep study and be sure he sleeps on his back when his apnea is at its worst. At 3 weeks post heart attack we are *not* interested in having him sleep without his CPAP! (Good grief, the pulmonologist even suggested he refrain from using his CPAP for 5-7 nights before he repeats the test )

Fortunately he's using my backup machine which is working very well for him. But he'd like to get his own machine again. So, since we're not planning to repeat the sleep study any time soon, we're probably going to ask his cardiologist to advocate for him with the Medicare powers-that-be. We're very lucky that we have the spare machine right now.

Does anyone know of a case where a Medicare denial of CPAP was successfully appealed?

[kteague]

I don't know the answer for sure, just thinking the doctor can specify things beyond the AHI that make it a medical necessity. Go over the details of the study. If there's any lacking of deep and REM sleep, or a lack of supine sleep in REM, the test would be termed by my doctor as "technically suboptimal". A technically suboptimal study should leave room for the doctor to reference prior diagnosis and medical changes to justify continued treatment. I wouldn't appeal until you have all your guns blazing. Sorry to hear you and your hubby are dealing with these issues and hope he's recovering well. I'm interested in your outcome with Medicare and will be following this.

[wardmiller]

Hubby is 3 weeks post heart attack and we just found out that the sleep test he completed last month for Medicare showed an AHI of 4.3. He's been using CPAP since 2011 when he was diagnosed and we know he needs it.

It isn't clear to me why he needs a NEW machine. Why can't he continue to use the machin he has been using? Did Medicare take his old one?

[Sheriff Buford]

Just a question...… : why do you think he needs a cpap machine with a 4 AHI?

Sheriff

[ChicagoGranny]

Pulmonologist assures us that Medicare will deny the new CPAP machine because his AHI was below 5 (we understand this to be accurate), so she doesn't want to go any further with trying to submit a prescription for him.
...

(Good grief, the pulmonologist even suggested he refrain from using his CPAP for 5-7 nights before he repeats the test )

Ewwww! I might not like this woman.

If you get past her reservations, the AARP site has instructions on appealing a Medicare denial. Best of luck.

https://www.aarp.org/health/medicare-in ... claim.html

[kaiasgram]

Pulmonologist assures us that Medicare will deny the new CPAP machine because his AHI was below 5 (we understand this to be accurate), so she doesn't want to go any further with trying to submit a prescription for him.
...

(Good grief, the pulmonologist even suggested he refrain from using his CPAP for 5-7 nights before he repeats the test )

Ewwww! I might not like this woman.

If you get past her reservations, the AARP site has instructions on appealing a Medicare denial. Best of luck.

https://www.aarp.org/health/medicare-in ... claim.html

Thanks Granny, we’ll check this out

[Pugsy]

I have heard about the hold over effect and why some docs suggest going without cpap for a period of time before doing a new diagnostic sleep study.
3 days/nights was what I have read as being the usual recommendation though.
I don't know how much of an impact the "hold over effect" actually can have with a person and it might depend on just how severe a person's OSA was in the first place. So the doc recommending going without cpap for a period of time before a repeat diagnostic test isn't totally unheard of. Would it make much of a difference??? Don't know and obviously comes with it's own baggage and you are damned if you do and damned if you don't. Apparently there is some documentation to the hold over effect though as I first read about it over on one of the sleep tech forums and subsequently had Dave mention it here.

[kaiasgram]

It isn't clear to me why he needs a NEW machine. Why can't he continue to use the machin he has been using? Did Medicare take his old one?

My goodness, this gang loves to throw out challenges! He needs a new machine because the one he'd been using since his diagnosis in 2011 finally expired. As I explained in my OP he's currently using my backup machine.

[Wulfman...]

Hubby is 3 weeks post heart attack and we just found out that the sleep test he completed last month for Medicare showed an AHI of 4.3. He's been using CPAP since 2011 when he was diagnosed and we know he needs it. Pulmonologist assures us that Medicare will deny the new CPAP machine because his AHI was below 5 (we understand this to be accurate), so she doesn't want to go any further with trying to submit a prescription for him.

Another option is to repeat the sleep study and be sure he sleeps on his back when his apnea is at its worst. At 3 weeks post heart attack we are *not* interested in having him sleep without his CPAP! (Good grief, the pulmonologist even suggested he refrain from using his CPAP for 5-7 nights before he repeats the test )

Fortunately he's using my backup machine which is working very well for him. But he'd like to get his own machine again. So, since we're not planning to repeat the sleep study any time soon, we're probably going to ask his cardiologist to advocate for him with the Medicare powers-that-be. We're very lucky that we have the spare machine right now.

Does anyone know of a case where a Medicare denial of CPAP was successfully appealed?

I'm confused........
What happened to his previous equipment?

viewtopic.php?f=1&t=114733&p=1112255&hi ... d#p1112255

viewtopic.php?f=1&t=89986&p=827021#p827021

Any knowledgeable "sleep doctor" would require that a person who is using CPAP refrain from using it for at least three nights before an in-lab sleep study.

Does he have a previous prescription that could be used to purchase some newer equipment? (presuming he no longer has his old stuff)

I presume that YOU have a prescription that could be used........

Heck, just buy some stuff out-of-pocket. There are some excellent, lightly-used (or even NEW) machines for sale "everywhere", if you look. Many have been offered recently on the forum, too.

Sorry to hear about his heart attack, but that should be a good reason to forge ahead and keep using XPAP.......with or without the prescription stuff. (Yes, I understand he's using one of your spares.)

Other than the initial purchase, I haven't asked any of my insurance providers to reimburse (or pay for) any of my purchases since I started. I did the math and found that between the co-pays and deductibles, I could buy it out-of-pocket as cheap or cheaper than relying on some insurance provider to help me.


Den

Edit: I just read your recent post.

.

[kaiasgram]

Just a question...… : why do you think he needs a cpap machine with a 4 AHI?

Sheriff

As I explained in my OP he was diagnosed in 2011 and has been on CPAP ever since. We don't just "think" he needs CPAP.

[kaiasgram]

I'm confused........
What happened to his previous equipment?

viewtopic.php?f=1&t=114733&p=1112255&hi ... d#p1112255

viewtopic.php?f=1&t=89986&p=827021#p827021

Any knowledgeable "sleep doctor" would require that a person who is using CPAP refrain from using it for at least three nights before an in-lab sleep study.

Does he have a previous prescription that could be used to purchase some newer equipment? (presuming he no longer has his old stuff)

I presume that YOU have a prescription that could be used........

Heck, just buy some stuff out-of-pocket. There are some excellent, lightly-used (or even NEW) machines for sale "everywhere", if you look. Many have been offered recently on the forum, too.

Sorry to hear about his heart attack, but that should be a good reason to forge ahead and keep using XPAP.......with or without the prescription stuff. (Yes, I understand he's using one of your spares.)

Other than the initial purchase, I haven't asked any of my insurance providers to reimburse (or pay for) any of my purchases since I started. I did the math and found that between the co-pays and deductibles, I could buy it out-of-pocket as cheap or cheaper than relying on some insurance provider to help me.


Den

Edit: I just read your recent post.

.

Hi Den, one way or another he will not be sleeping without a CPAP. And yes we can use my Rx for supplies, no problem there.

[Wulfman...]

Hi Den, one way or another he will not be sleeping without a CPAP. And yes we can use my Rx for supplies, no problem there.

You could also use it for the equipment (CPAPs and masks) themselves. Also, with some of these forum-offered machines, prescriptions wouldn't be an issue.


Den

.

[kaiasgram]

I don't know the answer for sure, just thinking the doctor can specify things beyond the AHI that make it a medical necessity. Go over the details of the study. If there's any lacking of deep and REM sleep, or a lack of supine sleep in REM, the test would be termed by my doctor as "technically suboptimal". A technically suboptimal study should leave room for the doctor to reference prior diagnosis and medical changes to justify continued treatment. I wouldn't appeal until you have all your guns blazing. Sorry to hear you and your hubby are dealing with these issues and hope he's recovering well. I'm interested in your outcome with Medicare and will be following this.

Hi Kathy, thanks for checking in. Unlike his first sleep study in 2011 which was an in-hospital study, the test last month was a home test and he slept on his side the whole time, something he can't normally do because pain keeps him changing positions during the night. He slept just the minimum number of hours to make it a valid test, and woke up with his "sans CPAP" headache. So it wouldn't necessarily be considered a suboptimal study, but it was not a representative night of sleep for him.

We'll get him another sleep study down the road, but in the aftermath of a heart attack we don't want him to be without his CPAP. I schlepped the machine to the hospital a few weeks ago so that he wouldn't be without it -- not going to put him through a non-CPAP night for a while to come! Thanks again for your thoughts and kindness.

[ChicagoGranny]

I just thought of something else?

He's been using CPAP since 2011 when he was diagnosed and we know he needs it.

Why was a new sleep test (HST) ordered? Medicare doesn't require another test when you are 65 as long as you submit a copy of the original test and evidence that you have been using CPAP. I'm suspicious that your sleep doc is a bungler or worse.

[palerider]

Just a question...… : why do you think he needs a cpap machine with a 4 AHI?

Sheriff

Because an AHI of 4 is bad. it's like being poked with a sharp stick every 15 minutes, all night long. It may be "good enough" for insurance or doctors, but it's really *not good* at all.

I feel like dog poo if my AHI is 4... heck, I feel worse if mine's over 2.