BiPAP S/T, Medicare, Sleep Study

[jdetray]

I have been using using a Respironics BiPAP S/T machine for nocturnal ventilation for about 15 years. I have central apnea and severe scoliosis due to childhood polio.

My current BiPAP S/T (I'm on my third one) was purchased by my former employer's insurance. I have since retired on permanent disability and am now covered by Medicare and a Medicare supplement policy. Medicare has never before been involved in paying for my BiPAP.

My existing BiPAP is quite old, and my pulmonologist has prescribed a new machine. What must my doctor and I do in order for Medicare to cover a new BiPAP S/T?

Two different DMEs tell me I will absolutely need a new sleep study to satisfy Medicare. I have read elsewhere that the results of old sleep studies may be sufficient. I have had several sleep studies in the past, but the most recent one was about 10 years ago.

I have no particular aversion to sleep studies, but it seems like a waste of time and money. My CO2 and O2 levels have been exceptionally stable and well-controlled with the BiPAP for 15 years. There is little or no chance that a sleep study will uncover anything new. The only reason for the study will be for obtaining Medicare coverage, and the study will likely cost more than a brand new BiPAP! In the end, Medicare will pay for both a sleep study and a BiPAP S/T.

Bottom line: Will I need a new sleep study in order for Medicare to cover my new BiPAP S/T machine?

Thanks,
Jeff

[StillAnotherGuest]

I guess it would depend on the extent of each of your diagnoses and then which ones are mentioned on the physician's order. If you're getting the BiPAP S/T (an "E0471" device) for post-polio and/or scoliosis, then you use these criteria:

• Restrictive Thoracic Disorders:
  
  A) There is documentation in the patient’s medical record of a progressive neuromuscular disease (for example, amyotrophic lateral sclerosis) or a severe thoracic cage abnormality (for example, post-thoracoplasty for TB), and
  
  B) 1) An arterial blood gas PaCO2 , done while awake and breathing the patient’s usual FIO2 is greater than or equal to 45 mm Hg, or
  
  2) Sleep oximetry demonstrates oxygen saturation less than or equal to 88% for at least five continuous minutes, done while breathing the patient’s usual FIO2, or,
  
  3) For a progressive neuromuscular disease (only), maximal inspiratory pressure is less than 60 cm H20 or forced vital capacity is less than 50% predicted, and
  
  C) Chronic obstructive pulmonary disease does not contribute significantly to the patient’s pulmonary limitation.

Once you mention central apnea, then you may have to re-establish the diagnosis.

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