Can I get some help with a Medicare question?

[cherylann]

I am new to Medicare and old to CPAP. I've been trying since 2010 and it just doesn't work for me. But, I want to take one more stab at it. My doctor wants to refer me to a sleep center in Texas (I live in Oklahoma). Does anyone know how this will work with Medicare? Will they pay for another sleep study (my last one was in 2011) and other related tests?

Has anyone had any experience with the Baylor Scott & White Sleep Institute in Temple, TX?

Thanks everyone.

[MarylandCPAPer]

I started on Medicare about 4 years after I got my CPAP machine, which was bought using Carefirst (BCBS) insurance. The DME said I had to wait to get a new machine under Medicare until my machine was 5 years old. They initially tried to get me a new CPAP machine when I first started on Medicare and were unable to get approval. YMMV.

[chunkyfrog]

My first machine was bought with BCBS in April 2010--while I was still working.
My latest machine was purchased in October 2014; about 4.5 years later!
My compliance had been ~100%, so no study was needed. (YMMV)
Call Medicare and ASK. DO NOT trust the doctor or DME to know.
Only Medicare will tell you the current requirements--as they can change.
Ask specifically if the sleep study will be covered, and the center in question.
The Medicare number is 1-800-633-4227

[Sheffey]

I started on Medicare about 4 years after I got my CPAP machine, which was bought using Carefirst (BCBS) insurance. The DME said I had to wait to get a new machine under Medicare until my machine was 5 years old. They initially tried to get me a new CPAP machine when I first started on Medicare and were unable to get approval. YMMV.

My machine was about 18 months old when I enrolled on Medicare. Medicare paid for a new machine.

But who knows, Medicare is backed by a complex and large bureaucracy, maybe I wasn't eligible for one and just slipped through the cracks.

[SewTired]

I am new to Medicare and old to CPAP. I've been trying since 2010 and it just doesn't work for me. But, I want to take one more stab at it. My doctor wants to refer me to a sleep center in Texas (I live in Oklahoma). Does anyone know how this will work with Medicare? Will they pay for another sleep study (my last one was in 2011) and other related tests?

Has anyone had any experience with the Baylor Scott & White Sleep Institute in Temple, TX?

Thanks everyone.

I'm confused. Your profile indicates that you already have a machine. Why would you need yet another sleep study? The machine you have auto-titrates.

[Krelvin]

Perhaps if you re-read her question it might help.

I am new to Medicare and old to CPAP. I've been trying since 2010 and it just doesn't work for me. But, I want to take one more stab at it. My doctor wants to refer me to a sleep center in Texas (I live in Oklahoma). Does anyone know how this will work with Medicare? Will they pay for another sleep study (my last one was in 2011) and other related tests?

[MarylandCPAPer]

The definite answer will come from contacting Medicare, but I can can tell you my experience. I started CPAP in 2009 after a sleep study. In 2015, I had 2 more sleep studies. The Sleep Center evidently had to get pre-approval from Medicare for the sleep studies, but I was told Medicare approved them. My dr. wrote 2 prescriptions, jumping through the hoops set by the sleep center and/or Medicare. One was for a sleep study with titration (a split night study). The other, which they also ended up using, was for just the sleep part without titration.

I never got to sleep the first night, so they could not do a titration that night. They said they needed at least 2 hours of sleep data before doing a titration.

They had me come back the next night, during which they attempted to do a titration. I slept for 2 hours and didn't go back to sleep, so the titration was essentially worthless because they started as so low a pressure range that they never got to the pressure range I need to be able to sleep.

If you have a machine capable of APAP (adjustable pressure) and if you had been using your machine regularly (as I had), data from the SD card could have been (and was) used to determine the prescription for a new CPAP machine.

A new sleep study was not required by the DME or Medicare to get a new CPAP machine, but my drs. and I hoped for information on my sleep problems from the recent sleep study. Unfortunately, for numerous problems on the sleep lab's part, the 2015 sleep studies were a total waste of time and taxpayer money, except to prove that I cannot sleep without a CPAP machine. The sleep lab was starting use of entirely new equipment the week my sleep study was done and they did not have enough equipment, such as Pulse Ox devices that clip on the fingers, for even half of the beds in the sleep lab. I found out all of this later when I complained about the useless sleep studies to the sleep lab manager. As far as I know, Medicare paid for the 2 nights of sleep studies.

[chunkyfrog]

After I dismissed Apria, Medicare has been a breeze, compared to BCBS.

[msla]

I am coming up on 5 years on my S9 Autoset. and 2+ years on medicare. I asked my new DME about replacement and he said Medicare wants patients to use the machine until it has a mechanical issue i.e. no blower, blower noises, dead power brick etc. This may be the new normal. The good news is that they only dispense full data auto machines and no bricks.

[MarylandCPAPer]

I am coming up on 5 years on my S9 Autoset. and 2+ years on medicare. I asked my new DME about replacement and he said Medicare wants patients to use the machine until it has a mechanical issue i.e. no blower, blower noises, dead power brick etc. This may be the new normal. The good news is that they only dispense full data auto machines and no bricks.

You might want to check with other in-network DMEs and directly with Medicare.

I would recommend getting a new machine at the 5-year interval if at all possible. My Phillips Respironics System One Autoset probably lasted 5 years, 2 months before its operations slowly starting shutting down, until in the end all i have is a leaf blower that I can plug in to turn on and unplug to turn off the blower. The process of gettting a new machine through Medicare seems to be rather tedious. I don't know the exact time, but I would say there may been a 1.4 to 2 month delay in getting a new machine after mine was essentially dead and I presented a new order for a machine from the doctor. I don't think the DME had to document that mine was dead, they just had to have proof that it was more than 5 years old. I got my new machine June 30, 2015, so if Medicare only wants to pay for new machines when the old ones are dead, mine qualified, but I was told Medicare would pay for a new machine after the current machine was 5 years old.

I hope that the new machine I got (Resmed Airsense 10 Autoset for Her) lasts 5 years, but if the policy is that they will replace a machine when it has a mechanical issue, particularly if it is sooner than 5 years, perhaps that is a good thing. There have already been recalls and problems with some A10 machines, and the A10 came out a year ago. Mine does not impress me as being as sturdy and durable as my old PR System One machine. Time will tell.

[cherylann]

I don't need a new machine. I have three of them. The first one was a CPAP obtained in 2010 after my first study. The 2nd one was a BIPAP obtained a couple of years later when a new doctor thought that was what I needed. The third one - the S10 - I got just before I went on Medicare a couple of months ago - I liked it because it looked easy to travel with and I wanted to make sure I had a good one before going on Medicare because I figure it will be my last one. I had BCBS for all there of these machines and they paid 100% - I never had to submit compliance reports.

Going to Baylor is just another attempt to find someone who can help me make this work. Five years, three machines, two sleep studies, three so-called sleep specialists, and four or five DMEs and I'm still struggling. I simply can't tolerate it. I don't know that they will want to do another sleep study - just assuming that.

Thanks to those of you who gave me good advice on this - I will call Medicare tomorrow. My doctor is making the referral tomorrow. This is a new primary care doctor and going to Texas was his idea. I probably should just keep muddling along like I am and wait for the inevitable.

[cherylann]

Something just occurred to me - does Medicare require that you be compliant in order to get your supplies and see a sleep doctor even if they don't pay for your machine? If they do, then I am screwed. I don't mind paying for my supplies out of pocket, but I'm not going to pay another doctor to just tell me I'm not trying hard enough.

[Stormynights]

All you need is a prescription. They will send you the supplies and masks. They will ask you if it is working for you and you will need to stretch it a bit and say yes. Maybe when it is time for a new machine that will change I am not sure. I really think that you have just not found the right mask that works for you.

[Worldwar2]

It's my understanding that medicare requires you to be seen by a doctor once a year in order for them to cover supplies. Most DMEs that I know of require that prescription in order to send/give you supplies.

[MagsterMile]

I've been on cpap since fall of 2012. I haven't see the Dr since late 2013 or early 2014. Haven't received any calls to come in and see him. It seems that once you are compliant with Medicare they don't require further info from you. The bills for supplies are submitted through my Medicare Advantage HMO and they are paid at reasonable cost. I pick up the balance - 20%. Of note: when I switched insurance to current plan, they had my reports faxed over by the doctor and that's the last I've heard of him.