Proof of OSA

[DJL]

I tried to order a new pillow for my mask because I can get one every month. The DME said that they have tried twice to get proof from the sleep doctor that I need to be on APAP. My sleep study about 4 months ago showed that my events were at 7.6 AHI and so that the second half of the study, I could not use a mask because I was below the 15 AHI that the insurance company requires before they pay.
Any way, I then went to the doctors office and said that the DME was trying to get proof that I have a medical need to be on APAP, the woman said that she had sent it to the DME, but that she would do it again. Two days after my visit the doctors office, the DME still had nothing, rang the doctors office and the woman said that she had sent.
It seems the proof only needs to be medical records were I answered the question how I was feeling. I had provided the DME with a prescription when I got my first mask off them.
I am trying to work out whats going on, has the doctor not got proof that I need to be on APAP and so I do not need to be on it. I did the sleep study and have had three visits with him and he explained why I need to be on APAP. I do not think that the DME would turn down an order from me because they will be making money.
Does it every happen that a doctor just strings patients along to get the money. He did say that I should go to his DME which he seem to have an investment in, but I went to any other DME which I had used for 5 years when I was on CPAP before. Or do DMEs turn down money, I have been very pleased with them, they have been very helpful and have not had any disagreements or anything.

Thanks Dave

[zoocrewphoto]

This seems strange. If they already have a prescription on file, why would they need some new proof? Are you trying to get a new machine or just a mask? Are they trying to sell you a new machine?

[JDS74]

Dave:

Now's the time to drop by the DME and ask exactly what they want from the doc.
They may be responding to a request from the insurance company so that they can get paid.

After that's straightened out, drop by the doc's office and get of copy of your medical records that comply with the request from the DME. This will likely be a HIPAA request and may take them a couple of days if they are too busy to just give you copies while you wait.

Make copies for your personal records and take a copy to the DME and close the loop.

It may be that the doc's office has the incorrect FAX number or address for the DME or that they are sending the records to the DME they recommend and not to the one you selected.

[hyperlexis]

I would consider switching MDs and everything else.

If someone puts you through the craziness of a sleep study, then you end up with a machine, yeah, you could be a red... you have sleep apnea!

Your MD needs to send the prescription or your medical record page showing a diagnosis of sleep apnea to the DME. If an MD's office cant manage sending a fax, the office is pretty incompetent.

[Pugsy]

What is your insurance company?
If Medicare there are certain requirements that have to be met to get past the "less than 15 AHI without cpap" thing.
https://www.noridianmedicare.com/dme/co ... _apnea.htm?
Scroll down and read the mumbo jumbo about exceptions to the "less than 15 AHI" rule.
The link may take you to a page where you see a prompt about accepting the agreement...just click on "I accept" if that happens and then you will be taken to the page that lists all the requirements and ways of meeting the requirements.

If you don't have Medicare..your insurance may be requiring similar documentation and the doctor's office notes may not be stating it...
Check with your insurance company to find out exactly what is needed.

The fact that your AHI is less than 15 may throw a big of a monkey wrench into things unless you have other factors involved.

There's more to getting insurance companies to pay for something sometimes than just the doctor providing a RX.
If it was that easy I would get a RX for a hot tub for my arthritis and get my insurance company to pay for it.

full explanation at the link above..this is part of the requirements...
An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:

The beneficiary has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea.

The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

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:

Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

Hypertension, ischemic heart disease, or history of stroke.

[kteague]

I recently went through something similar trying to get a new mask from a new place under Medicare. The provider has certain documentation that must be in their files or they'll get in trouble. They told me their file needs to show I need the treatment, that I'm using it, and doctors visit notes stating that I was benefitting from the treatment. Now, that was a general conversation on starting with a new DME, not necessarily a checklist of requirements. I heard some version of this from two different DME's I contacted. I gave up and paid cash from our host here because all my documentation was too old for the DME and it would have cost me more in medical visit and testing co-pays to get current information. I don't blame the DME's on this though. They are trying to follow the letter of the law so they can stay in business. If you are willing to persist you CAN get set up at the DME. You would think a doctor would know what kinds of info is needed by insurances and would include it in his visit notes for every patient. And maybe he has. Looks like you'll have to hand hold them through this to get exactly what you need. Bummer.

[chunkyfrog]

I wonder if there is a list somewhere that one can take to some of the more clueless docs to make sure that all the ducks are lined up.
There is nothing on Medicare.com; and a call to Medicare indicated they have no detailed list they can send or email out.
All I can gather is they need proof that cpap is medically necessary, and helps, and that you use it.
I was told that my sleep test, taken 3.5 years ago, is "good enough", even though the lab is not even Medicare approved.

[oak]

I wonder if the hangup is that the doctor is not specifically stating that djl needs to be on APAP, vs CPAP. Someone is not communicating well with someone else. Maybe djl should go to the dme's office when they call the triage nurse in the doctors office (NOT A SECRETARY) to get the message across as to exactly what needs to be written on the prescription. Then they can tell the doctors office that djl will PICK UP the prescription---no faxing.

However, the sleep study tech may have known something that either the DME or the doctor don't know, and that's that your insurance won't pay for treatment for mild apnea.
" I could not use a mask because I was below the 15 AHI that the insurance company requires before they pay." I bet if you talk with your insurance you may find out that they are not going to pay, no matter whether the doctor says you need it or not--the doctor doesnt have "proof" that you need it. I know my insurance, for example, will not pay if the patients AHI is under 15 at the time of the sleep study, and I have very liberal, very good insurance.

[LinkC]

You should ALWAYS have a current copy of your prescription. This is just one example of why that's important.

[StuUnderPressure]

All I can gather is they need proof that cpap is medically necessary, and helps, and that you use it.
I was told that my sleep test, taken 3.5 years ago, is "good enough", even though the lab is not even Medicare approved.

I know someone who got an APAP in Feb 2013 paid by Medicare with a Sleep Study done 15 years ago.

The lab is not the one that is Medicare approved.
Medicare only requires that the Sleep Study meet their "current" requirements for a Sleep Study. Basically, that only means that the right medical terms are used in the report of that Sleep Study.

[DJL]

After many more phone calls to DME and doctors office, the doctors office said that they are have a technical problem and cannot printout my medical records.
Its strange that they did not say this a week or so ago, instead of just says that they we send the info to the DME.
Only time will tell if I get the medical records or not.

Dave

[oak]

Does one of the doctor's employees have a problem with the truth or what. WEIRD. Something is not right.

[chunkyfrog]

I believe that with a co-morbidity, like high blood pressure, untreated AHI only needs to be over 5.
Mine was only 13, but I had no problem getting insurance coverage.

[BlackSpinner]

After many more phone calls to DME and doctors office, the doctors office said that they are have a technical problem and cannot printout my medical records.
Its strange that they did not say this a week or so ago, instead of just says that they we send the info to the DME.
Only time will tell if I get the medical records or not.

Dave

Just walk into the office and tell them to hand write it out while you wait. Bring a project to work on.