Medicare???

[mattman]

Medicare does cover CPAP equipment. They have some qualifications/restrictions in place that you will have to meet.

Readers Digest Version: You'll need a DX code of 780.53 and a Sleep Study showing an AHI of 5 or greater for Medicare to cover. Medicare covers 80% of DME (It's under Part B Medicare). The remaining 20% would be paid for either you or your supplemental insurance (If you have it and if you have DME coverage on that insurance).

Longer Version:
The patient does have to be diagnosed with Obstructive Sleep Apnea (780.53) or they won't cover the device. There are a few exceptions to that but they are VERY few, very restrictive and will require extensive extra work to get covered.

This is important because many docs will write the more generic Sleep Disorders (780.50) which will NOT qualify under Medicare.

As mentioned before, Medicare does require compliance tracking during the rental period. If you do not use the device enough Medicare will suspend coverage and payment and require that the device be picked back up.

Medicare requires the device be rented for 12 months and then converted to a purchase. Ostensibly this is to weed out people who won't use or can't adapt to the device. The idea was that Medicare would stop paying for those people and it would save them money in the long run. Of course, that's not how it's ended up working out but that was the logic behind the original design.

Once the device is covered all the supplies will be covered as well (Masks, filters, etc). The inverse is true as well - if coverage is denied for any reason, supplies are denied as well.

That should answer most of your initial questions. It's confusing as hell to be sure, but that's the gummint for you.

Matt

[cpapquuen1]

327.23 is the dx code nowadays accepted by MCR. They have been denying the old 700 code.

[nursedeborah]

Thanks Matt,
I live in Calif, and I don't have to pay anything at all, just have to use it for 30 days, send in the
chip, and then they see if I am using it more than 4 hours daily, and if not I do get 2 more
months to keep trying to get used to it. If not then your going to really have to either buy one,
or the reason for not using it must be documented daily, and told to the DME company, and your
doctor.

The stupid thing is I know so many who have this, and don't wear it, and just keep complaining about
being so tired. I just don't even want to listen. Wear the thing!!! It took me over 3 years to even
get anyone to listen to me, and I ended up with Central Apnea too! I was not breathing 140 times
an hour no wonder I slept for those years, or couldn't function!!!!

Debbie

[Madalot]

I browsed this thread and don't think I missed it, but in case I did --

You must be disabled for two years before you qualify for Medicare. However, because it sometimes takes FOREVER to get approved, if they backdate your actual date of becoming disabled and it's more than two years back from the APPROVAL date, you get both at the same time.

For example: Let's say you get approved for disability on March 1, 2010. But they claim you became disabled on March 1, 2008. You're already at the two-year mark, so you qualify for Medicare at the same time. But if they said you became disabled on March 1, 2009, you have to wait another year before you get Medicare.