Medicare CPAP Replacement Question

[Boothnagel]

I have been using CPAP therapy for over 5 years now. Last week my physician wrote a prescription for a new machine after I reported increased noise and a faulty humidifier. My DME provider filed a claim with Medicare which was denied as their records indicated my CPAP utilization was 9 months short of the 5 year threshold. Here's the rub. For the first 9 months of my CPAP therapy, I was enrolled in a Medicare Advantage health insurance program but switched to traditional Medicare Part B with a supplemental policy so my sleep study and first 9 months of CPAP charges were billed to The Medicare Advantage company, not to traditional Medicare. I have documentation to that effect but can't find any Medicare policy that covers this situation. I have tried calling Medicare several times but can't seem to connect with anyone in the know. Any insight board members would care to provide would be greatly appreciated.

[ChicagoGranny]

My DME provider filed a claim with Medicare which was denied as their records indicated my CPAP utilization was 9 months short of the 5 year threshold.

Based on a document cited below, I suspect your DME made a mistake on the claim. The DME should have shown on the claim the date the equipment was delivered to you. Could they have mistakenly used the date of your switch to Medicare Part B with a supplemental policy?

Computation of the useful lifetime is based on when
the equipment is delivered to the patient, not the
age of the equipment.

http://www.resmed.com/us/dam/documents/ ... achine.pdf

The document is advice to DMEs about the Medicare rules for replacing a CPAP machine. It might be helpful to read the rest of the document.

[Boothnagel]

Your help is greatly appreciated. I suspect you are correct regarding the DME provider. I will follow up with them to see how the claim was filed. The document you linked is helpful. Thanks again.

[Pap-Daddy]

Last week my physician wrote a prescription for a new machine after I reported increased noise and a faulty humidifier. My DME provider filed a claim with Medicare which was denied as their records indicated my CPAP utilization was 9 months short of the 5 year threshold.

IF it costs too much to repair it - it can be replaced early. Look for another DME and be sure to get a loaner while it is out for repair/estimate.

No idea where you are located or where you are calling but Medicare is open pretty late and they do have people who specialize in specific areas, keep trying. If you don't have a spare I'd pick one up on Craigslist, check under Health and Beauty and search this forum for other discussions on those topics.

[chunkyfrog]

When you call Medicare on your cellphone, plug it in.
Long waits could kill your battery right when you get connected.
Murphy works the switchboard.

[Grouch]

I have been using CPAP therapy for over 5 years now. Last week my physician wrote a prescription for a new machine after I reported increased noise and a faulty humidifier. My DME provider filed a claim with Medicare which was denied as their records indicated my CPAP utilization was 9 months short of the 5 year threshold. Here's the rub. For the first 9 months of my CPAP therapy, I was enrolled in a Medicare Advantage health insurance program but switched to traditional Medicare Part B with a supplemental policy so my sleep study and first 9 months of CPAP charges were billed to The Medicare Advantage company, not to traditional Medicare. I have documentation to that effect but can't find any Medicare policy that covers this situation. I have tried calling Medicare several times but can't seem to connect with anyone in the know. Any insight board members would care to provide would be greatly appreciated.

Wish I had better news, but...

I ran into this very same thing last fall, when my sleep doc ordered a new machine on my 5th year anniversary. Medicare said I still had 6 months until my 5 years was up. What? Turned out that my Medicare advantage program had been lax in sending their information and payment to Medicare. The first record Medicare had was 6 months after I started therapy.

After many phone calls, I was able to talk to someone in another part of Medicare, who could see the actual start date in their computer system, but it didn't matter. Everyone agreed that I had met the 5 year time - Medicare, my doc, the DME, but none of that mattered. The only thing that counted was the official date entered in some part of the Medicare system. That couldn't be changed. I had to give up.

Fast forward 6 months. Just got my new machine last month.

[LSAT]

Unless your machine broke, it's really not imperative that you must have a new machine at 5 years. It's nice, but really not a critical issue. Most machines last a lot longer than 5 years.

[ChicagoGranny]

I was able to talk to someone in another part of Medicare, who could see the actual start date in their computer system, but it didn't matter. Everyone agreed that I had met the 5 year time - Medicare, my doc, the DME, but none of that mattered. The only thing that counted was the official date entered in some part of the Medicare system. That couldn't be changed. I had to give up.

I wonder what would have happened if your DME had resubmitted the claim with the correct start date?

It will be interesting to see what Boothnagle comes up with.

[ChicagoGranny]

Everyone agreed that I had met the 5 year time - Medicare, my doc, the DME, but none of that mattered.

You may have had an additional problem ------>

If a DME item reaches its five-year life expectancy, is
in good working order and meets the patient’s medical
needs, it should not automatically be replaced.

http://www.resmed.com/us/dam/documents/ ... achine.pdf

Even when five years old, a statement is needed from the doc saying the machine no longer meets your needs.