Boyce wrote:Janknitz wrote:some insurers will not cover CPAP and supplies without a diagnostic sleep study. Medicare is one such insurer
You might be wrong about that as far as Medicare goes. I've been using Medicare for 19 months now and they have paid for a new machine, masks, hoses, etc.
I haven't had a sleep study in over a decade and that practice was closed down (Medicare fraud) and I have no idea where my study records are.
The doc that I have been using for a couple of years now told me he would certify annually with Medicare that I have sleep apnea and am compliant with CPAP.
I just had my annual this morning where they read the card and submit a compliance report to Medicare.
I am another one who would refuse a diagnostic study - too dangerous due to the severity of my apnea.
Your 10 year old sleep study must be adequately documented somewhere in the "system" or you have managed to slip under the radar.
Check this out:
http://www.cms.gov/Outreach-and-Educati ... 905064.pdf
Center for Medicare and Medicaid services sets the Medicare rules. Reimbursement (to the DME) for CPAP will be denied for a variety of reasons including:
Common PAP Device Errors
1. No documentation of the treating physician’s initial face-to-face clinical evaluation conducted
before the sleep study to assess the patient for Obstructive Sleep Apnea (OSA).
2. No physician documentation that a physician, a physician assistant, a nurse practitioner,
or a clinical nurse specialist has had a face-to-face encounter with the individual involved
during the 6-month period preceding such written order.
3. No documentation of a Medicare-covered sleep study supporting medical necessity.
4. No documentation of the treating physician’s signed and dated order describing the
item(s) dispensed.
5. No documentation of the treating physician’s face-to-face re-evaluation, within the first
three months of initiating therapy (but after the 31st day), which documents both improvement
in subjective symptoms of OSA and objective data related to adherence to PAP therapy.
6. No documentation of continued need and continued use.
PAP devices for the treatment of OSA are covered by Medicare
only if they meet the criteria
in Tables 2 and 3 on pages 4 and 5. For additional information on detailed written orders, visit
the Medicare Program Integrity Manual (PIM), Chapter 5, Section 5.2.3 at
http://www.cms.gov/
Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c05.pdf on the CMS website.
Table on page 4 for initial treatment says:
B. A Medicare-covered sleep test that meets one of
the following:
1. The Apnea-Hypopnea Index (AHI) or
Respiratory Disturbance Index (RDI) is greater
than or equal to 15 events per hour with a
minimum of 30 events; or
2. The AHI or RDI is greater than or equal to 5 and
less than or equal to 14 events per hour with a
minimum of 10 events and documentation of:
a. Excessive daytime sleepiness, impaired
cognition, mood disorders, or insomnia; or
b. Hypertension, ischemic heart disease, or
history of stroke.
And it covers the criteria if you came to Medicare with the diagnosis of sleep apnea on page 5:
For patients who received a PAP device prior to enrollment in 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:
1.
The patient had a documented sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the patient seeks Medicare coverage of a replacement PAP device and/or accessories; and
2.
The patient had a face-to-face clinical evaluation, following FFS Medicare enrollment, by the treating physician who documented in the patient’s medical record that:
a.
The patient has a diagnosis of OSA; and
b.
The patient continues to use the PAP device.
If either criterion 1 or 2 above is not met, the claim will be denied as not medically necessary.
In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.
(no requirement for clinical re-evaluation or objective documentation of adherence because Medicare isn't going to pay).
According to the rules, no sleep study, no Medicare coverage.
