Update: Any chance of appealing Medicare denial of CPAP?

[palerider]

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

I don't know, but... alternatively.. what kind of machine does he need, and could LSAT or grayghost4 supply it, and just tell doctor and medicare to go 'eff themselves?

[kaiasgram]

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

Sheriff

Because an AHI of 4 is bad.

Yes, that too!

[kaiasgram]

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.

Granny, I don't know the answer yet -- His first and only other sleep test was in 2011 when he was first diagnosed, and he was 66 at the time, so Medicare covered his first (and only) machine. The motor crapped out on that machine a few months ago.

Are you saying that he didn't really need another sleep study to get a replacement machine covered by Medicare? He did provide the sleep doc with his 2011 sleep study report as well as the data from his SD card showing compliance. We believed that was sufficient and the doc thought so too at first.

[kaiasgram]

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

I don't know, but... alternatively.. what kind of machine does he need, and could LSAT or grayghost4 supply it, and just tell doctor and medicare to go 'eff themselves?

He uses an APAP. For the time being he's fine with my backup machine (S9 Autoset). I bought this machine a couple of years ago from cpap.com when they were having a terrific sale. Kept it in the box to use as my backup until a few months ago when hubby's gave up the ghost. So we're good for now and don't need to run out and buy on the private market. If we have to though, we will. His cardiologist may be willing to go to bat for him on an appeal, given his recent hx. Fortunately we are not in an urgent situation and can wait to see if we can get the machine through Medicare -- it's definitely a big hassle, but he served, has Medicare and Tricare for Life, and legitimately needs his machine replacement. But he's got my backup machine in the meantime.

[ChicagoGranny]

He did provide the sleep doc with his 2011 sleep study report as well as the data from his SD card showing compliance. We believed that was sufficient and the doc thought so too at first.

Your doc's first thoughts seem to have been correct. My doc, who seems to know what she is doing, said a machine over five years old would be replaced with a statement from the doctor that the patient still needs the machine and the machine no longer meets the patient's needs. A face-to-face meeting with the doctor would be required. A new sleep study is not needed.

ResMed's Medicare Replacement Guidelines seem to confirm that. https://www.resmed.com/us/dam/documents ... achine.pdf

I think your doctor has botched this up.

[kaiasgram]

He did provide the sleep doc with his 2011 sleep study report as well as the data from his SD card showing compliance. We believed that was sufficient and the doc thought so too at first.

Your doc's first thoughts seem to have been correct. My doc, who seems to know what she is doing, said a machine over five years old would be replaced with a statement from the doctor that the patient still needs the machine and the machine no longer meets the patient's needs. A face-to-face meeting with the doctor would be required. A new sleep study is not needed.

ResMed's Medicare Replacement Guidelines seem to confirm that. https://www.resmed.com/us/dam/documents ... achine.pdf

I think your doctor has botched this up.

Thanks very much for finding this, Granny. We will contact our primary or his cardiologist to pursue this -- we haven't been impressed with the pulmonary staff from the beginning.

[greatunclebill]

have you doc send a prescription to the dme. the dme will tell him what they need from him to 'git 'er done.

[kaiasgram]

have you doc send a prescription to the dme. the dme will tell him what they need from him to 'git 'er done.

That was the first thing we did...

[Sheriff Buford]

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.

mmmmm


Sheriff

[SewTired]

If your study has been submitted to Medicare, it could be an uphill battle and you may have to pay for another study out-of-pocket to be reconsidered. Just want you to know that it is a possibility.

[Okie bipap]

Medicare will pay for as many studies as the doctor thinks you need. I had four done before I finally got my machine, and my wife had three. My first doctor ordered my sleep study before he documented a face to face meeting where we discussed sleep apnea. After reviewing the results, he scheduled me for a titration study. Since he did not document the required first face to face meeting, I had to repeat everything before I could get my machine.

[chunkyfrog]

Could the doc be playing the system to get extra bucks out of Medicare?
Whatever the case, if there is fraud, it is on the DOCTOR--not the patient.
Just do what is needed to git er done.
And let the chips fall on the quack!

[CPAPforever]

Medicare regs do not allow home sleep studies. They must be done in sleep study lab. Do you know what AHI was in study done in 2011 and what desat level was?

I would get a legitimate sleep study in a sleep lab and then submit new Rx instead of appeal. Wait until your hubby has recovered and able to safely do sleep study. Does Tricare pay the 20% not covered by Medicare?

If you buy used without Rx, you won't be able to have his CPAP supplies covered by Medicare. Those masks can be expensive.

Shouldn't have done home study but water under the bridge now. Medicare won't pay for CPAP with AHI under 5 so appeal useless.

[Pugsy]

Medicare regs do not allow home sleep studies. They must be done in sleep study lab.

That was changed a couple of years ago.
https://www.sleepapnea.org/medicare-app ... p-studies/

[CPAPforever]

I just read the regs last week. It says sleep study must be in lab. Will post link to reg.