Information, PLEASE

[MsPat]

I have a SleepEasy with heated humidifier CPAP machine. Have had it since September. Since reading so much on this forum, I have come to the conclusion that I was given the most basic machine there is. It gives me NO info except how long I have it on each night. Since I am on Medicare with a suppliment, do I have any recourse in getting a better machine???
I was not offered a choice, but only given this one. Can anyone tell me what my options are at this point?
I do seem to sleep better, but don't feel much different during the day. How do I know if I am having any apnea episodes, etc???
Thanks for any help you may be able to give.

[rjjayrt]

At this point if your DME does not want to exchange your machine and your not willing to go out of pocket to purchase one online, the only way you could get a new machine would be to have your physician write a prescription for a fully data capable machine. Medicare may want or require a new sleep study or a new certificate of medical necessity.

[nobody]

If you don't feel much different during the day, that would be a good reason to have a data-capable machine. You would need a prescription for it to get the DME to exchange it and Medicare/supplement to pay for it. I don't think you'd need a new sleep study, though.

[Madalot]

Yes, Medicare guidelines can make this a pretty hectic ride. I know it did for me.

When I first reported to my doctor that I was having trouble breathing at night, she did her testing in her office. It showed slightly below normal readings. She said if it were up to her, she'd just prescribe the equipment (most likely bipap) but based on my results, Medicare wouldn't pay for it. Being pretty thorough, she said that we'd do the sleep study and see if we could prove, that way, that I needed the equipment. But even then, we had to start with cpap. But she was diligent about writing her orders for data capable equipment, plus ordering overnight pulse ox testing on a regular basis to make sure everything was okay. Obviously, it wasn't as I've been moved to bipap, bipap with oxygen and now moving to a ventilator system today.

But she had to do it in a certain order to ensure we didn't have problems with Medicare. I'm lucky to have pretty savvy doctors working with me.

Because you haven't posted more information about your specific situation, it's hard to know exactly what you should do, but I would start by asking your doctor about keeping track of your situation through data and such and see what he says.

[MsPat]

Called my DME provider this afternoon. HMMMMPF!!! I was told that nothing could be done. I asked if it would do any good for me to call Medicare. I was told NO that they would not approve any of the machines with a smart card. Also, that I would have to wait another 4 & 1/2 years for another machine.
However, I could get my doctor to write a prescription for a titrated cpap trial for one week & they would give me (for 1 week) a smart card machine to see if anything needed adjustment.
I then called my supplemental insurance carrier & they told me that if I called Medicare & they approved a new RX for another machine they would pay for it. So, that call will be made tomorrow morning.
DME said I could always buy one out of pocket for around $1400.00 How very helpful of them!!!!

[JohnBFisher]

If you are forced to buy out of pocket, just go to an online shop, like CPAP.com. The price is better and it sounds as if it would not be hard for the service to be better.

[rosiefrosie]

MsPat I love your kitty and I am a dog person. Sorry I know this is off your topic, but I could not resist.

rosie

[Judy R]

MsPat, welcome to the DME GRRRRRRRRRR Club! . I know how fustrating all of this is, most DME's are just out for that almighty dollar, and do not want to help the patient. But, with that being said, there are some DME's out there, {very rare I might add} that are willing to help us. Good for you, for taking the Bull by the horns. The more you are in control of your therapy the better. This is a great place to get tons of information and tons of wonderful folks here to give advice, and help you with questions and any help or road blocks you may come across. This is a great group of people! Let me just add this..... "I love your kitty too!" shewwwwwww, now I've got that off my chest, I'm good to go!

[mattman]

Here's what I can offer...

"technically" speaking, the DME provider is correct.

Medicare will only pay for a new CPAP device every 5 years. Once the bill gets submitted to Medicare, you are basically "locked" in. Medicare doesn't care if the machine doesn't do everything you want - what they care about is "Does this machine treat sleep apnea". If the answer is yes, they are happy.

Also, your supplemental insurance rep was correct but unfortunately also wrong. They WILL pay for a machine if Medicare approves it. The problem it, Medicare wont approve a new machine for the reasons outlined above. The supplemental insurance actually doesn't even figure into the picture here since the claim basically "stops" at Medicare.

NOW - that being said - here are some options:

1) First thing I would try is exactly what they offered - do a 1 week trial on an APAP. That will really help pin down if your treatment isn't currently sufficient. This is a machine that can automatically adjust pressure based on what it picks up in your breathing. This generally is not charged to your insurance as it's usually just going to be a freebie loaner.

2) You can *try* to get a new prescription for a new data-capable machine. Note that the doctor will have to outline a specific CLINICAL reason why your current device IS NOT TREATING your Sleep Apnea. Again, Medicare doesn't care that a data capable machine can do it better. That is going to be a very steep obstacle to overcome. Then the claim would go before the Medicare review board. Again, this is a very steep obstacle to overcome. Note that this process often easily goes well over 6 months to a year.

3) Talk to your current provider. Work with them. Explain that you aren't feeling better and that you have worries that your numbers may be off from what you were prescribed. If you have other specific issues (Maybe things like mouth breathing, Aerophagia, etc) and see what they can suggest to help alleviate these issues. Work directly with the DME providers RT. Often times, working with them (Rather than the more common approach of walking in, demanding a new machine and threatening to leave if they don't do it) can really help solve a lot of problems.

I hope that helps some.

mattman

[MsPat]

Mattman~~Thanks for the sound advice! I will try it "your" way! Certainly is discouraging, tho'!
What ever would we do without all you people willing to help???!!!!
Thanks again!

[akcpapguy]

This IS really very simple!

Is your CPAP on rent still? (Most Medicare regions require the CPAP to be on rent for 13 months, I only say most because I don't know ALL of the reules for EVERY region.)

If the answer to the above is YES, than go to your physician (Sleep or General it doesn't matter either one can write the Rx) and get him/her to write an Rx worded as such.

CPAP (insert your pressure)cmH2O, heated humidifier, mask of patients choice and all other supplies. CPAP must include ability to download compliance and efficacy data via removeable media. Lifetime need.

OR
Auto CPAP 4-20 (don't worry about the range we will help you dial that in)cmH2O, heated humidifier, mask of patients choice and all other supplies. CPAP must include ability to download compliance and efficacy data via removeable media. Lifetime need.


Both of the CPAP's listed above bill to Medicare with the same HCPC code (E0601) that your current machine does, there is NOTHING for Medicare to aprove, there is NO change to the billing!!!!!!!!!!!

I cannot stress this enough so I will say it again, if your Physician writes you an Rx one of the two ways I stated above there is NO approval required from Medicare IF your CPAP is under the 13 month rental.

[Papillon2]

MsPat,
My husband and I are in the same boat that you're in. We were both given entry-level machines within the last month, and would now like to upgrade the machines. It makes no sense to me that we can't just opt to pay out of pocket for the upgrade, over the cost of the basic machine. After all, the only difference is the data gathering capability--the machine's therapeutic functions are the same. It also makes no sense that a doctor wouldn't automatically request a data-gathering machine. How else can a doctor determine if therapy is effective? Without data, the evaluation of therapy has to be completely subjective. I just don't understand why this whole thing is set up as it is with both medicare and the insurance companies.

[Jersey Girl]

Ms. Pat,

I love your cat! Wherever did you find him?

Here's hoping that you will be able to get the machine you need...affordably.

Warmly,

Jersey Girl

[montana user]

At this point if your DME does not want to exchange your machine and your not willing to go out of pocket to purchase one online, the only way you could get a new machine would be to have your physician write a prescription for a fully data capable machine. Medicare may want or require a new sleep study or a new certificate of medical necessity.

The research I've done on Medicare and Medicaid ( please double check your self ) is once your diagnosed with sleep apnea, you have it for life. The one lab I worked at, if a mdcr/mdcd Patient came in for a re-titration and it had been 5 years or longer, we would have to start from scratch to "re-qualify" them. when I took over this lab, I researched it some, and was told there was NO need to prove they have apnea again. Something to look into anyway.

[MsPat]

AKCpapguy~~Like the info you provided. IYHO do you think I shoud do the 1 week trial on full data capable loaner first??