New Medicare Policy on Machines?

[OwlCreekObserver]

I've been on CPAP (Respironics Remstar Pro 2) for a little over three years. That machine now has about 7500 hours on it and has been making a whining noise. Because I recently turned 65, becoming Medicare eligible, I planned to talk to a sleep doctor about getting another sleep study and, hopefully, a new machine.

However, a relative tells me that her DME just told her that Medicare is very reluctant to approve xPAP machines these days because so many people just put them in the closet and don't use them. I have no doubt that they're right about many new users eventually giving up on treatment -- I STILL think about it from time to time -- but to say they're not approving new machines just doesn't sound right to me. She was told this by a DME in Nashville and I'm wondering if anyone else has heard anything like this.

OCO

[The Texan]

Got mine this Feb through Medicare without any problems. I am beginning to believe every DME makes up their own rules about Medicare to suit their desires. Everyone is saying the Medicare is different in every state, but no one can post any information to support this statement other than "my DME told me". All the information I can find says that Medicare is the same nationally and they are still supporting CPAP without any problems and on a posted national schedule, not a state or regional schedule.

[Slinky]

She just ran into a local DME supplier who is not too smart, is too cheap or ....

Medicare has changed their ruling somewhat, whereas before just a signed form letter from the patient verifying they were using their xPAP 4 or more hours a night, 5 or more nights a week was sufficient to justify continued Medicare payment for the device, the new ruling requires that the DME supplier be able to provide documented proof via data from the devices that the device is truly being used consistently.

That doesn't mean the DME has to supply a fully data capable xPAP - BUT - it DOES mean that they are going to have to provide an xPAP capable of providing AT LEAST compliance data. AND that the DME is going to have to follow up w/their clients to download that compliance data and have it on file in their office in order to be assurred of reimbursement. There are those cheapskate DME suppliers who have been foisting off bottom of the line xPAPs not even capable of compliance data on their unsuspecting clients and who never bother to contact their clients after providng the equipment except to mail out the form letter for the client to fill out, sign and return.

Medicare does divide the country into 3-4 "regions" and reimbursement amounts tend to vary somewhat between regions but not all that much so far as I've been able to determine. They may reimburse more - or less - in CA vs in MI as an example. And it seems to me I read that they have picked a specific area to try out a new policy on before adopting or dropping it.

Medicare has recently adopted a new policy of paying for at-home sleep studies and APAP (or maybe it is CPAP) use for 3 months as a screening process.

Since you are now on Medicare I would suggest you go to mymedicare.gov and sign up so that you can access your benefits online more quickly than waiting for the snail mailed EOB and to check out further info. Its a pretty handy site.

[Rjjay]

Medicare now requires the date of the initial appt, the objective reasons for the sleep test, compliance download after 30 days proving compliance and date of followup appt documenting improvement. All of this needs to be completed between the 31 and 90 day. If not, Medicare won't pay past 90 days.

[janp]

To add to the information ...

Medicare rents/leases the machine for 13 months, after which you own the machine. They continue however to support you on replacement materials.

If you want to know exactly what/when supplies you're entitled to, get a copy of Medicare's document L171. I've worked with three DME's locally ... none of them had ever seen the document!

For me, the DME did a telephone survey for 3 months to ask how many hours a night I used the machine. They wanted to hear "4 or more hours". That 90 day period satisfied Medicare.

Jan