Using Medicare to Replace a Defective CPAP

[earossi]

New to this board, but diagnosed with sleep aphea about 10 years ago, and a successful user of a cpap since then. My current machine, a Resmed S8 Elite, is about 6 years old, and has developed a failure of the on/of switch. With its age and the onslaught of a mechanical issue, I think I would like to replace the machine. So, I have several questions:

1. Since the cpap continues to deal effectively with my apnea, must I go through another sleep study in order to be able to replace the old cpap machine?

2. My local physician provided a prescription to replace the old machine; however, he simply wrote on the script "replace cpap machine". What other data needs to be supplied for the script to be acceptable for the purchase of the new machine? I'm assuming that the script should at least have my single pressure setting that was set up in the old machine.

3. Will Medicare cover the outright purchase of a new machine, or simply cover the rental of a machine? If renting, will Medicare cover rentals forever? If not, what is needed to renew the rental?

4. In researching replacement machines, it appears that modern technology has improved since I purchased my S8 Elite 6 or 7 years ago. Is the Auto S9 the new and current state of the art for cpap macines? If so, what data must be on the prescription in order for Medicare to cover the cost of t he machine?

[Slinky]

Medicare "rents to own" for 13 months and then the PAP is yours. The integrated humidifer, mask, accessories are outright purchases.

It wouldn't surprise me if Medicare would require a new titration study since they weren't involved w/your original Dx and purchase of equipment and it has been so many years since your studies. But I don't know that for sure.

Yup, the script would require your pressure setting and if you are going to want a humidifier the script should also specify heated humidifier.

If you want an auto titrating PAP your script would need to specify a range of pressures, i.e. 1-2 cms below your current pressure and 2-3 cms above your current pressure, for instance 7 cms - 11 cms pressure.

[hopingitworks]

Below is a recent thread that may answer some of your questions as well. I am sure others will chime in.

viewtopic.php?f=1&t=83826&st=0&sk=t&sd=a

[scbeaver]

I am going through this at this time. Medicare will replace a defective machine, broken switch works. You need a copy of your sleep study, mine is five years old but is OK. Next, see your DR and make certain that it is documented, have him write the script (keep a copy). After you get your machine, you MUST get a follow up visit in the 31 to 90 day time frame. Medicare requires coompliance of 4 hours per day for 70% of the first 30 days of ownership. This will be a 13 month caped rental on the machine. everything else is a purchase.

Sleep well,

Steve

[avi123]

Since this is more than 5 years, I agree that it may be difficult to get Medicare to pay for this repair.

Jankntiz has written recently:

Medicare will cover a replacement machine if its in need of extensive repair. It used to be that Medicare would cover a new machine every five years, but I think they now want the DME to present some reason for the replacement. Likewise they will replace supplies according to a published schedule, but now they are asking for a reason for replacements. This is because DMEs made a lot of money supplying consumables even when not needed.

If I was in this situation I would pay cash for a new machine, and supply. I have seen enough how my DME charged Medicare exorbitant amounts.

[Janknitz]

Medicare will cover your new machine, I'm not sure if they will require a new sleep study or not, the DME should be able to tell you that.

HOWEVER, you should ask your doctor to write a very specific script so the DME does not try to saddle you with a brick. If you want the S9 Autoset, be sure your doctor specifies it in the prescription. It should say "ResMed S9 Autoset set at X cm/H20, heated humidifier and hose, mask of patient's choice". To be extra sure, ask your doctor to put a range of pressures, so they don't try to push a straight CPAP on you (this is NOT specifically required, but the DME will be less likely to balk at the prescription if it has a range). Ask your doctor to also write "Dispense as written". And then make darn sure they don't try to do a bait and switch and give you a ResMed S9 Auto Escape model instead. The S9 Autoset is the most expensive machine, and since the DME makes not an extra dime on it, they would prefer to give you the cheaper escape model.

Don't worry one bit about what the DME charges for the machine. That is NEVER the Medicare allowed amount. Medicare determines what it will pay, and you (or your supplemental insurance) owe the remaining 20% of the monthly rental fee set by Medicare, assuming the DME "accepts assignment" (most do). If the DME issues something called an Advance Beneficiary Notice (ABN) stating that they want to charge you more than the allowable Medicare rate, then find another DME who will accept the Medicare rate (most will). You have the benefit of Durable Medical Equipment through Medicare, you paid for it over many years of hard work, nothing wrong with using it.