anybody use medicare to pay for studies and gear?

Kharris · Post by **Kharris** » Tue Jul 15, 2008 8:21 am

My dad's doctor had finally talked dad into doing a sleep study.
does anyone have experience with what medicare will pay for.?
thanks

Slinky · Post by **Slinky** » Tue Jul 15, 2008 8:38 am

Medicare allowed and paid 80% for my sleep evaluation study and even for a second titration study when I didn't sleep long enough my first (42 mnutes out of 6 hours bedtime).

In addition, Medicare allowed and paid 80% for my Resmed S8 Elite w/EPR 13 month capped rental and purchase of mask, all necessary equipment, etc. And when, 17 months later, my sleep doctor determined due to my COPD that I needed a new sleep evaluation and a bi-level titration, Medicare paid 80% of both, plus is currently paying 80% of the necessary 13 month capped rental for my Resmed VPAP Auto.

Medicare has been insisting on a 13 month capped rental for xPAPs after which time it becomes the property of the patient. The mask and humidifier and other supplies are outright purchase at time of provision.

In addition they continue to pay 80% of necessary supplies as needed.

Now, they did just recently institute a new policy on allowing 3 month trials of xPAP therapy w/o the in-lab evaluations and titrations. However, the in-lab evaluation for "first-timers" is preferable from the patient's standpoint as far as the in-lab evaluation being able to determine any other sleep disorder in conjunction w/or instead of "just" OSA.

jomac30 · Post by **jomac30** » Tue Jul 15, 2008 7:16 pm

How did you get Medicare to pay for another machine after such a short time? they told me I would have to purchase it first, then send in request for them to pay for it. My doctor wrote a letter of medical necessity and a new prescription. They told me they don't do prior approvals. I have to go from Cpap to Apap. Does that make a difference?

6PtStar · Post by **6PtStar** » Tue Jul 15, 2008 7:29 pm

Cpap and apap are the same class. In order to get medicare to pay you have to go to a bipap or SV which are a different code for medicare.

Jerry

Gerald · Post by **Gerald** » Tue Jul 15, 2008 7:54 pm

Kharris.......

Medicare paid for most of my sleep study (2-nights), but I didn't "qualify" for Medicare to pay for the equipment....because my AHI was just below 5.0......the point at which....in their infinite wisdom.....I didn't need any therapy. They were "dead wrong"....and I knew that I was gonna be dead if I didn't get myself on the hose pronto!

Because I live in a "last place town in a last place state", my sleep study was of poor quality....and I had to assume responsibility for my own therapy. I knew I was in deep trouble (BP spikes over 200 systolic at night) regardless of what the crappy sleep study said. I had measured my BP myself.

I purchased my own Auto CPAP....with CFLEX.....fully data capable....with software....smart card reader....humidifier....oximeter....and a spare. I bought first class equipment....not the low-end stuff I would have "qualified" for had Medicare been paying the bill. In effect, I was free to purchase what really works....not what just "appears" to work.

My equipment is wonderful......my BP is under control....I feel great......and I'm 100% compliant. I've been on the hose since Sept of 2006. I love my equipment....and I wouldn't want to change a thing.

So, I would suggest that you let Medicare pay for the sleep studies....then purchase your own data-capable equipment....regardless of what Medicare or the doctor says. Don't let them convince your Dad that he doesn't need the capability of monitoring his own progress with your computer. If you listen to them, you'll be dependent on their poor quality service....and your Dad's chances of success will be limited.

Gerald