Medicare guidelines for replacement?

[jobe2433]

Hello, I just switched to a new DME company because of the competitive bidding program. I was told today that medicare only covers tubing, headgear and water chamber every 6 months? Is this correct? Last year I would get new head gear, tubing and water chamber every 3 months. Any info would be great since I can't seem to find what's covered and when.

[LSAT]

Hello, I just switched to a new DME company because of the competitive bidding program. I was told today that medicare only covers tubing, headgear and water chamber every 6 months? Is this correct? Last year I would get new head gear, tubing and water chamber every 3 months. Any info would be great since I can't seem to find what's covered and when.

Why in the heck would you need those items every 3 months. You may want them every 3 months but they last a whole lot longer. I use the Quattro and have been using the same mask and head gear for about 15 months. My hose is 9 months old and I have no problem with it. My Humidifier cup is the original that came with my machine 1 year ago. I have back ups on every thing, but, even though Medicare will allow a replacement every 6 months ...I certainly don't need a replacement that often.

[purple]

LSAT, what is true for you in terms of need for replacement is not true for everyone. Some of us use pressures which I suspect may be higher than yours, which reduces the elasticity of the mask cushion, and head straps, coupled with different type of skin, this can cause a lot of pain. Please keep in mind that as we get older often our skin gets thinner, causing it to break more easily and to heal very slowly.

Right now I am going through a lot of pain because I have I need to pull the straps tight, and they have no elasticity left, When I wake up hours later, I have pain from how tight the mask on my face, and worse, I have leaks I do not have early in the cycle of mask, head strap replacement.

I do not disagree that that what you say is true for you, just it is not true for me, and I suspect others here.

I have Medicare, and I had thought that the mask, hose replacement is every three months, and the head straps are every six months. However, that was last year.

[LSAT]

LSAT, what is true for you in terms of need for replacement is not true for everyone. Some of us use pressures which I suspect may be higher than yours, which reduces the elasticity of the mask cushion, and head straps, coupled with different type of skin, this can cause a lot of pain. Please keep in mind that as we get older often our skin gets thinner, causing it to break more easily and to heal very slowly.

Right now I am going through a lot of pain because I have I need to pull the straps tight, and they have no elasticity left, When I wake up hours later, I have pain from how tight the mask on my face, and worse, I have leaks I do not have early in the cycle of mask, head strap replacement.

I do not disagree that that what you say is true for you, just it is not true for me, and I suspect others here.

I have Medicare, and I had thought that the mask, hose replacement is every three months, and the head straps are every six months. However, that was last year.

I never mentioned cushions in my post. If you need to pull the straps so tight that you still have leaks and pain,...you have the wrong size or the wrong mask.

[SleepWellCPAP]

Regarding replacement of xPAP supplies, most insurances follow Medicare guidelines. Below I will paste the latest schedule and the link to what is call the local coverage determination. In that document you'll find details about the strick criteria required for a provider to submit claims. It sure isn't as easy as it used to be. The parenthesis indicate my clarification on the code.

-------------- 2014 CGS LCD for xPAPs--------
Accessories used with a PAP device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not reasonable and necessary.

The following table represents the usual maximum amount of accessories expected to be reasonable and necessary:

A4604 (climate line tubing) 1 per 3months / A7027 (oral/nasal combo mask ie Liberty) 1 per 3 months / A7028 (Oral cushion for the combo) 2 per 1month / A7029 (Nasal pillows for the combo) 2 per 1month / A7030 (full-face mask, includes headgear) 1 per 3 months / A7031 (cushion for FFM) 1 per 1 month / A7032 (Cushion nasal mask) 2 per 1 month / A7033 (Pillows for nasal mask ) 2 per 1month / A7034 (Nasal cushion or pillows mask, Airfit/Swift/Mirage) 1 per 3
months / A7035 (Headgear for any mask, note code for masks includes the headgear, this is for providers if they separate it and most don't) 1 per 6
months / A7036 (Chinstrap) 1 per 6 months / A7037 (tubing) 1 per 3 months / A7038 (disposable filters) 2 per 1 month / A7039 (reusable filters) 1 per 6
months / A7046 (humidifier chamber) 1 per 6 months

Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.

http://www.cms.gov/medicare-coverage-da ... AAA%3d%3d&

Hope that helps.

[SleepWellCPAP]

To answer the posters question, in general, headgear and water chambers can be billed at six months, but the tubing is once every three months.

I don't know why last year was different from your provider as the MCR schedule was the same then. Of course, it's possible especially with the Blue Cross Blue Shield folks, that the interval differs from MCR.

The easiest way to get an accurate answer for a particular policy is the call the insurance directly and give them the codes I posted above.

[avi123]

At my new Medicare DME provider (b/c of competitive bidding program) I see this:

{For the Full Face mask cushion I think that it's one every month and not every months}



So I don't need to clean my nasal mask cushion b/c I can get a new one free every 2 weeks