What is ethically reasonable to ask of us?

[Sonnyboy]

I don't think Medicare is requiring a yearly prescription.

Compare the CMS-10269 form [Medicare] with the Prescription / Letter of Medical Necessity form Cpap.com will send to physicians on request.

It looks like some doctors and some DME's add the yearly requirement.

I can't find anything that says this is a Medicare requirement.

[Nick Danger]

I think it is reasonable to insist on the following - borrowing from Latinist, Robysue and Janknitz:

- A sleep study to diagnose OSA
- AHI should be calculated using both 4A and 4B and the larger of the two is used for diagnostic purposes
- up to 2 sleep studies may be required in the initial year: one for diagnosis, one for titration
- additional sleep studies should not be required more frequently than every 5 years unless a physician determines that it is medically necessary
- demonstration of compliance (no more than annually)
- no distribution of machines that do not provide comprehensive data
- no unbundling of bundled items to drive up reimbursements (e.g. charging separately for mask and headgear when those are sold together, removal of bundled nasal pillows from the package, charging separately for xPAP machine and humidifier when they are available as a bundle)

[purple]

Uh, ongoing need? So after over five years of my using Sleep Apnea, I had more than half a night of a was supposed to be a titration study first wasted on proving that I STILL NEEDED Sleep Apnea Treatment. Moreover, the standard said I had to sleep over four hours without xPAP to prove I needed it. After five hours I asked the tech to come in and get my nitroglycerine out of my stuff (I was basically tangled down) and they were asking if I needed to go to the ER for heart pains. What a stupid waste of what should have been a Titration Study. When the tech comes in and says the pulse ox came off your finger, and oh no, it is on your finger. But ones O2 is going low because I am on my back, and I can not sleep at all. DUH. Patient must sleep four hours to comply with standard. DUH.

[Nick Danger]

I hear you Purple. There are very, very few cases of spontaneous recovery from OSA, but I suspect that insurance companies and medicare will want some sort of confirmation from time to time.

[Festerann]

Newbie question: what is a DME? I checked the glossary, not entry for this one

[candlegirl76]

Newbie question: what is a DME? I checked the glossary, not entry for this one

I just learned this one today at my appointment! DME = Durable Medical Equipment (provider).

[Nick Danger]

Hi, Candlegirl,

Please start a new topic and let us know how your DME appt went

[Darth Lady]

Medicare now demands that I visit a Sleep Doctor once a year to continue to get supplies (masks, head straps, hoses, and I guess filters.) I see someone who does not want to see a sleep doc to get a new prescription for a machine, when the last time they saw a doc was four years ago.
...
If you were testifying to Congress as to what the laws should be for xPAP, what would you tell them they should do?

I'd tell them recognize Rule 4B as a legitimate way to score hypopneas for demonstrating the need for a CPAP under Medicare regulations.

The biggest problem I have with Medicare (which does NOT cover me---yet) is that Medicare only recognizes hypopneas if they are scored under "Rule 4A", which demands that there be a 4% drop in the O2 saturation level. Rule 4A ignores the fact that many people do not have this big of a drop during their hypopneas. The American Academy of Sleep Medicine recognizes the fact that some people repeatedly arouse before the desats happen and they have an alternative standard (Rule 4B) for scoring hypopneas. Under Rule 4B, if the airflow decreases by 50% and there is an associate arousal in the EEG OR a 3% drop in the O2 saturation, a Rule 4B hypopnea can be scored.

Sheesh, I hope someone comes up with a cure for this condition before I turn 65 because I guess that's when I'll be stopping treatment - I'm one of those people who rouses before hitting 4% most of the time. So if I have to "prove up" with a sleep study, they'll boot me off. I guess Medicare considers that as long as we're awake, we've got noooooooooo problem!

Or I'll just get my buddy Boba Fett to cobble together equipment and wing it...

[Krelvin]

- no unbundling of bundled items to drive up reimbursements (e.g. charging separately for mask and headgear when those are sold together, removal of bundled nasal pillows from the package, charging separately for xPAP machine and humidifier when they are available as a bundle)

The assumption that most people have is that the items are sold the to the vendors the way you think they are when in fact, it could be quite different.

For example, I am currently playing with a list of Resmed machines listed on the FAA list. It is amazing how many of the same units have different model/Ref numbers. Digging deeper, it is very apparent that some of the models are sold in packs of 2, 3 and perhaps more for the same exact unit.

It is quite possible, that units sold in bundles like this are done so with items that you would think would come with the unit not included. Some of the model/ref numbers appear to be assigned to bundled machines as well, unit with the H5i humidifier AND the climateline hose. Yet others are sold without. You don't have to have a climatline hose with a H5i humidifier and it is possible they are sold that way to the vendors.

It is also possible that when you are buying a pack of X that they may only include the base unit, no case, no hoses, no filters etc..

Who knows. That is part of the problem, nobody knows how the units are actually sold... but a lot of people are assuming they know. I don't know.

[134]

My doctor told me to never even take a nap without using my cpap, so why am I then forced by my insurance company every 2 years to have an additional sleep study sleep without using a cpap....This is DANGEROUS! We know we have sleep apnea so why put our heart and lives at risk sleeping without one in order to "get approval" for a new machine.

What happens if I have a heart attack or stroke during the test without the machine.

[zoocrewphoto]

Who knows. That is part of the problem, nobody knows how the units are actually sold... but a lot of people are assuming they know. I don't know.

I saw mine removed from the box. And the box held the humidifier, tank, and hose in addition to the machine.

I have also been lied to. Told I could not order a mask without the head gear. Or that my headgear was not available in small size. I switched DMEs and got the small headgear. When I ordered a new mask and new headgear, they came in separate packages, so clearly a mask can be purchased without the headgear.

[Krelvin]

Who knows. That is part of the problem, nobody knows how the units are actually sold... but a lot of people are assuming they know. I don't know.

I saw mine removed from the box. And the box held the humidifier, tank, and hose in addition to the machine.

Okay, I'm currious, do you know the Ref number is on your CPAP? I ask because there are 15 different ref# for the unit you have listed as your CPAP machine. They represent, singles, bundles, unbundles, co-packs, tri-packs etc... 15 different combinations for the same unit.

Ref # for "S9 AutoSet CPAP Machine"
36005
36015
36025
36105
36115
36125
36145
36205
36225
36245
36265
36305
36325
36345
36365

[palerider]

Who knows. That is part of the problem, nobody knows how the units are actually sold... but a lot of people are assuming they know. I don't know.

I saw mine removed from the box. And the box held the humidifier, tank, and hose in addition to the machine.

Okay, I'm currious, do you know the Ref number is on your CPAP? I ask because there are 15 different ref# for the unit you have listed as your CPAP machine. They represent, singles, bundles, unbundles, co-packs, tri-packs etc... 15 different combinations for the same unit.

Ref # for "S9 AutoSet CPAP Machine"
36005
36015
36025
36105
36115
36125
36145
36205
36225
36245
36265
36305
36325
36345
36365

the machines are never labeled with the bundle number. an autoset is 36005, or maybe 36005a... it doesn't matter what else was in the box.