Update: Any chance of appealing Medicare denial of CPAP?

[Pugsy]

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

Please provide a current resource if you find one. I found lots of old documents stating in lab only but nothing new since the notice that the asaa posted a couple of years ago.
Home studies have come a long way in the last 10 years and if you get a type II home study it pretty much records everything that is recorded in a sleep lab. I think that Medicare requires a more complete/thorough home study though. The most basic pulse ox only home study still isn't covered.

[Janknitz]

Kaisgram, do I remember correctly that you have Kaiser?

Does your husband? If so you are facing an uphill battle because Kaiser Senior Advantage is both his healthcare provider and his Medicare intermediary. No incentive to go beyond the guidelines because their Medicare reimbursement is capitated and they make money by spending less on him. So you won't be fighting "Medicare", you'll be fighting your own provider who will have it's thumbs firmly planted on the physicians who are supposed to be your husband's advocates.

Getting Crapria involved won't help, because all they are is a supplier. Kaiser is technically also the DME. Crapria just supplies the machines.

If the cardiologist will go to bat for you, you might have a chance. But it's kind of a stacked deck with Kaiser.

[kaiasgram]

Kaisgram, do I remember correctly that you have Kaiser?

Does your husband? If so you are facing an uphill battle because Kaiser Senior Advantage is both his healthcare provider and his Medicare intermediary. No incentive to go beyond the guidelines because their Medicare reimbursement is capitated and they make money by spending less on him. So you won't be fighting "Medicare", you'll be fighting your own provider who will have it's thumbs firmly planted on the physicians who are supposed to be your husband's advocates.

Getting Crapria involved won't help, because all they are is a supplier. Kaiser is technically also the DME. Crapria just supplies the machines.

If the cardiologist will go to bat for you, you might have a chance. But it's kind of a stacked deck with Kaiser.

Hi Jan -- No longer with Kaiser, we both have Medicare and Tricare for Life

Pugsy: Thanks for correcting the info about home sleep studies

[Janknitz]

Hi Jan -- No longer with Kaiser, we both have Medicare and Tricare for Life

Ah, good to know. I understand that Tricare for life is more than "just" a Medicare supplement, so you may try to see if they will cover the CPAP even if it doesn't meet the requirements under Medicare. You might ask for an "Evidence of Coverage" document to see what their CPAP coverage criteria is.

I just had my own incident with Kaiser when they charged over $4000 for a rather routine echo-cardiogram for my daughter when what I asked for was a pediatric cardiology consult. A knowledgeable cardiologist with a stethoscope could have done this screening easily--they wouldn't let her see one. And if I had known what the charge was I would have shopped around for a cash price from another provide--or I think she might be covered for it under one of the state programs like California Children's Services. Our share with Kaiser was supposedly $1670! Ordinarily an insurer would negotiate with a provider, but Kaiser is both our insurer and provider with NO incentive to negotiate.

Fortunately, I persisted in appeals and turns out they coded it incorrectly so all we owed was our $75 deductible. Took 3 months and multiple visits to patient services, multiple phone calls and hours on hold to work it out. Some people would not have questioned this charge or would have given up and paid the billed amount.

Crazy!

[kaiasgram]

Hi Jan -- No longer with Kaiser, we both have Medicare and Tricare for Life

Ah, good to know. I understand that Tricare for life is more than "just" a Medicare supplement, so you may try to see if they will cover the CPAP even if it doesn't meet the requirements under Medicare. You might ask for an "Evidence of Coverage" document to see what their CPAP coverage criteria is.

I just had my own incident with Kaiser when they charged over $4000 for a rather routine echo-cardiogram for my daughter when what I asked for was a pediatric cardiology consult. A knowledgeable cardiologist with a stethoscope could have done this screening easily--they wouldn't let her see one. And if I had known what the charge was I would have shopped around for a cash price from another provide--or I think she might be covered for it under one of the state programs like California Children's Services. Our share with Kaiser was supposedly $1670! Ordinarily an insurer would negotiate with a provider, but Kaiser is both our insurer and provider with NO incentive to negotiate.

Fortunately, I persisted in appeals and turns out they coded it incorrectly so all we owed was our $75 deductible. Took 3 months and multiple visits to patient services, multiple phone calls and hours on hold to work it out. Some people would not have questioned this charge or would have given up and paid the billed amount.

Crazy!

I'm sorry to hear about your daughter and all the hassles with Kaiser. I had quite a few hassles with Kaiser too, and I feel very lucky to have the plan(s) I have now. Tricare is amazing and hubs and I both feel very lucky to have it.

[Okie bipap]

Tricare for life will cover what Medicare covers. I got my first bi-level machine through Medicare and Tricare for life. Medicare was my primary coverage, and I had to satisfy all of their requirements which meant I had to go through two sleep studies and two titration studies because my first doctor did not document the required face to face meeting before ordering the first sleep study. Tricare for life paid my copay for all of the sleep studies and the machine. I purchased a second machine for a back up from a private individual. When my wife had her sleep studies done, they thought she might need an ASV machine due to the high number of CA events she had when she first started using a machine. She use my spare machine for four months until the decided she did not need the ASV machine, and they finally ordered her bi-level machine. I recently purchased a second back up machine from an individual to be a back up machine for her.

[ChicagoGranny]

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

Here are the current regulations straight from the web page of the Centers for Medicare & Medicaid Services:

The AHI and/or RDI may be measured by polysomnography (PSG) in a facility-based sleep study laboratory, or by a Type II home sleep test (HST) monitor, a Type III HST monitor, or a Type IV HST monitor measuring at least 3 channels.

https://www.cms.gov/Medicare/Coverage/C ... /CPAP.html

Home Sleep Studies were added to the coverage schedule 10 years ago:

NEW / REVISED MATERIAL
EFFECTIVE DATE: March 13, 2008
IMPLEMENTATION DATE: August 4, 2008

https://www.cms.gov/Regulations-and-Gui ... R86NCD.pdf

[SewTired]

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

I concur with the others. Home sleep study is allowed if you qualify for it. I don't (heart problem).

[Janknitz]

From the horse's mouth: (Emphasis mine)

CMS National Coverage Determinations for Medicare: https://www.cms.gov/medicare-coverage-d ... AAAA%3d%3d&

Indications and Limitations of Coverage

B. Nationally Covered Indications

Effective for claims with dates of service on and after March 3, 2009, the Centers for Medicare & Medicaid Services finds that the evidence is sufficient to determine that the results of the sleep tests identified below can be used by a beneficiary’s treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and necessary under section 1862(a)(1)(A) of the Social Security Act.

1. Type I PSG is covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed attended in a sleep lab facility.

2. Type II or Type III sleep testing devices are covered when used to aid the diagnosis of OSA in beneficiaries who have clinical signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

3. Type IV sleep testing devices measuring three or more channels, one of which is airflow, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

4. Sleep testing devices measuring three or more channels that include actigraphy, oximetry, and peripheral arterial tone, are covered when used to aid the diagnosis of OSA in beneficiaries who have signs and symptoms indicative of OSA if performed unattended in or out of a sleep lab facility or attended in a sleep lab facility.

[palerider]

I think y'all have well and truly shown that CPAPforever has no idea what their talking about. Hopefully they'll be more careful in the future about adamantly proclaiming wrong statements.

[kaiasgram]

Thought I'd let y'all know what's happened with our case.

Those of you who said that a repeat sleep study is not necessary per Medicare guidelines are of course correct.

What happened is that the pulmonologist switched us to a different DME without really thinking it through. The new DME naturally said they need the original sleep study report. Rather than *look* at the original report which we literally handed to her at our appointment, the doctor simply ordered a new sleep study. And as those of you following this thread know, the second sleep study fell just short of the AHI needed for a new machine. Had the doctor taken a little more care, she would have just sent the original sleep study to the new DME and never ordered another sleep study.

The person who actually straightened all of this out for us was the lovely angel nurse who does post heart attack follow-up phone calls during the first month of recovery. Hubs happened to mention the CPAP issue to her last week and she said "that doesn't sound right, let me see what I can do." She just called -- she's faxing the original sleep study to the DME we'd been using all along, and they will issue the replacement machine.

Time for a new pulmonologist.

Thanks to those of you who pointed out that hubby shouldn't have needed another sleep study. This was the first time one of us needed a new machine since going on Medicare, and we've now learned our lesson.