Medicare and New Machine

[Elle]

When I had had my old machine a little over 5 years the DME emailed to tell me I was eligible for a new machine. I called the insurer and they said they would replace my old machine if it was broken and couldn't be repaired.

The RT came to my place to "check my machine" and said it was fine. I was puzzled and told her that her company had told me they ordered a new machine. She said she thought she was just coming to check mine. She hadn't been told anything else. She called them and they said they had indeed ordered a new one so that was that.

I am assuming the DME told the insurer my machine couldn't be repaired and they needed a new one covered.

(They told the insurer it would cost $2900. for the S9 autoset. Insurer paid $2200.)

[amos]

I am now one month into my new ResMed S9 Elite which was approved by Medicare. I used the ResMed S8 Elite for over 5 years. Medicare calls it a "restart." The new machine comes as a 13 month rent to own as did the old machine. The only difference is that I do not have prove compliance with the new machine.

amos

[newname]

so, what I get from this discussion is that medicare will provide a new machine every five years and it doesn't have to be because the old machine is broken and there is no need for a doctor's letter of medical necessity.
Am I correct in assuming this?

[idamtnboy]

so, what I get from this discussion is that medicare will provide a new machine every five years and it doesn't have to be because the old machine is broken and there is no need for a doctor's letter of medical necessity.
Am I correct in assuming this?

Not quite. Your doctor has to substantiate that you still need it. Here's a quote from Medicare about this

REPLACEMENT:
This section applies to PAP devices initially provided and covered while the beneficiary was in Medicare fee-for-service (FFS).

If a PAP device is replaced during the 5 year reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test, or trial period.

If a PAP device is replaced following the 5 year RUL, there must be a face-to-face evaluation by their treating physician that documents that the beneficiary continues to use and benefit from the PAP device. There is no requirement for a new sleep test or trial period.

This comes from Local Coverage Determination (LCD) for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L171) which applies to most of the plains and western states. I think this requirement is probably uniform across all the states.

[drdavedmin]

Just to add another detail from someone who just purchased out of pocket and is on Medicare. My DME in a former state slipped me a non-auto machine as I was moving, and it was too late by the time I discovered it. Now after a new sleep study in a new state, with a higher pressure required, I am unable (in less than 5 years) to get Medicare to pay for an auto machine.

My new DME tells me that a regular CPAP and an auto machine (APAP) are the same Medicare code and Medicare will pay the same amount for each one, and that even an appeal for a new machine is highly unlikely to be granted because of that. So I bought a Devlibiss Intellipap auto out of pocket - gulp. But it seems to be a very good machine.

[amos]

newname,

Yes, Medicare will replace your old machine after five years. It will be on a "rent to own" thirteen month program and is called a restart.

Yes, your doctor does have to write a new prescription or letter of necessity.

amos

[chunkyfrog]

In a related question; if the current machine is under 5 years old,
but purchased prior to Medicare, (by BCBS at work)
does the papper have to wait until that machine is 5 years old to get one under Medicare?

[idamtnboy]

In a related question; if the current machine is under 5 years old,
but purchased prior to Medicare, (by BCBS at work)
does the papper have to wait until that machine is 5 years old to get one under Medicare?

Here's the pertinent quote from that LCD above.

BENEFICIARIES ENTERING MEDICARE:
For beneficiaries who received a PAP device prior to enrollment in fee for service (FFS) Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the following coverage requirements must be met:
Sleep test – There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and
1.
Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating physician who documents in the beneficiary’s medical record that:
a. The beneficiary has a diagnosis of obstructive sleep apnea; and
b. The beneficiary continues to use the PAP device.
2.
If either criteria 1 or 2 above are not met, the claim will be denied as not reasonable and necessary.
In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.

Wait for it to be 5 yrs old? Doesn't flat out say one way or another, but the implication is yes. It's possible if you just plain started over again, sleep study, etc., if the doc agrees, Medicare may pay for it all. The only way to know for sure is to ask them.

I think it's correct to say the above provisions apply only if you are under original Medicare Part B. It's whole different ball game if you are in a Medicare Advantage plan.

[stolzy]

I got a Phillips 50 serious machine and I can not get a heated tube for it but where I got my machine he said medicare care will pay for a new one but I had to consult with my Doctor and and then get a new prescription for a new one stating the reason I need one

[Sir NoddinOff]

I got a Phillips 50 serious machine and I can not get a heated tube for it but where I got my machine he said medicare care will pay for a new one but I had to consult with my Doctor and and then get a new prescription for a new one stating the reason I need one

Kind of an old thread to append to and not sure if you have a question however good luck getting the hose setup you will undoubtedly need.

[mike1953]

I got a Phillips 50 serious machine and I can not get a heated tube for it but where I got my machine he said medicare care will pay for a new one but I had to consult with my Doctor and and then get a new prescription for a new one stating the reason I need one

Read and learn
https://www.medicare.gov/coverage/sleep ... ories.html

[chunkyfrog]

Update: i got my Airsense 10 Autoset for Her when my S9 Autoset was only 3-1/2 years old.
Medicare covered it, since somebody else (me) paid for the S9.
My capped rental ended several months ago.

[LAGrandpa]

Update: i got my Airsense 10 Autoset for Her when my S9 Autoset was only 3-1/2 years old.
Medicare covered it, since somebody else (me) paid for the S9.

Did you have to do a new sleep study?

[chunkyfrog]

Heck no! Just a note from my doctor (PCP) asserting that I use my cpap and benefit from it.
This is the yearly face to face required by Medicare.

[idamtnboy]

I just got my new Airsense 10 yesterday. Haven't fired it up yet, but maybe tonight. I've had my S9 for 5 1/2 years.

The DME rep said Medicare requires 90 day compliance monitoring and a doctor visit, I think in about 90 days, to verify all is well, I guess. After that it's truck on like the last 5 years. He has no idea why the compliance monitoring is needed with 5 1/2 years of history in the folder.