Medicare CPAP Compliance Rules

[Photomatt]

Does anyone have a reference to the government regulations (number, URL, or PDF, etc.) regarding Medicare CPAP compliance rules.

I once saw somewhere that for CPAP, only the patient had to certify compliance, but for BIPAP it required a physician certification. I can't remember where I saw that. I have searched the internet and this forum, and can find a lot of conflicting talk about it but nowhere could I find the actual regulation.

Any help would be appreciated. I am trying to change physicians and I don't want problems with certifications of compliance.

Thanks, all.

[Slinky]

First and most important, if you have correctly indicated the CPAP you are using, the PR SystemOne Pro w/Flex, then you have no worries about your compliance data being available whether your local DME provider or sleep doctor follow thru on their end of the situation or not - IF - you are faithfully using your PAP.

What I am NOT sure about is what changes Medicare may have made to the requirement that a patient MUST use their PAP at least 4 hours a night at least 5 nights a week. I'm pretty sure I've read that those rules have been tightened somewhat but can't say what the new regs are.

Use your CPAP each and every time you sleep, whether for a nap or for the night.

[DreamOn]

See this .pdf document: http://www.sleephealth.com/Collateral/D ... 0019_0.pdf. While this is not a direct link to the government regulations regarding CPAP compliance requirements for Medicare, it does state, in part:

"Medicare requires 4+ hours/night of use ≥ 70% of the nights in 30 consecutive days for continued coverage for PAP therapy.... Adherence to therapy is defined as use of PAP ≥ 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not medically necessary."

[Guest]

also, you have to go for a face-to-face follow-up visit with your sleep doc between the 31st & the 90th days. The sleep doc has to provide documentation of said follow-up to the DME for them to file with Medicare, along with your compliance data.

[Patrick A]

I got a new machine on December 22, 2009. I received a phone call from the DME that supplied my new Bi-Pap machine in January they asked me to read the numbers from the screen on my machine. 7 day reading and 30 day reading. I went in to my sleep doctor in March he also sent in a compliance report to Medicare.

[Photomatt]

Thanks folks for these responses. But what I really need is the regulation itself.

There is so much talk about it but I can't find it myself.

I have been 100% compliant since getting the machine on March 25th. I saw one medical professional, the nurse practitioner on May 26th who can certify my compliance to that date. I don't want to go back to that office. However, I don't know whether I MUST go back to someone. I would just as soon never see any of them again but certainly not the one with the level of competence that I observed. So I would like to see the regulation and what is REQUIRED. What form must be filled in, by whom, and sent to whom is the data I am seeking.

I believe I am quite competent at adjusting my titration myself. I have been using CPAP for 12 years. However, I just got this new machine under Medicare so I must follow their rules. I have Encore Pro 2.2, and download/examine the data every day. So, I know what is going on. The medical office I went to could only see the waveform data for the last day, whereas I have it for every day and can see trends and patterns that they could not. Moreover, the competence of the technician, measuring the CPAP pressure left much to be desired. However, that is another story which would probably be too boring for most.

So, thanks again, all. But if someone could cite the actual regulation, it would be very much appreciated.

[Janknitz]

OK, It was a bugger to find, but the exact Medicare criteria is in the "local coverage area determinations" and it reads as follows:

CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:
Continued coverage of a PAP device (E0470 or E0601) beyond the first three
months of therapy requires that, no sooner than the 31st day but no later than the
91st day after initiating therapy, the treating physician must conduct a clinical re-
evaluation and document that the beneficiary is benefiting from PAP therapy.
For PAP devices with initial dates of service on or after November 1, 2008,
documentation of clinical benefit is demonstrated by:
1. Face-to-face clinical re-evaluation by the treating physician with
documentation that symptoms of obstructive sleep apnea are improved; and,
2. Objective evidence of adherence to use of the PAP device, reviewed by the
treating physician.
Adherence to therapy is defined as use of PAP > 4 hours per night on 70% of
nights during a consecutive thirty (30) day period anytime during the first three
(3) months of initial usage.
If the above criteria are not met, continued coverage of a PAP device and related
accessories will be denied as not medically necessary.
Beneficiaries who fail the initial 12 week trial are eligible to requalify for a PAP
device but must have both:
1. Face-to-face clinical re-evaluation by the treating physician to determine the
etiology of the failure to respond to PAP therapy; and,
2. Repeat sleep test in a facility-based setting (Type 1 study).

http://www.nationwidemedical.com/wp-con ... gion-d.pdf

I didn't check each and every local coverage area, but I suspect they are all the same.

I don't know whether I MUST go back to someone. I would just as soon never see any of them again but certainly not the one with the level of competence that I observed. So I would like to see the regulation and what is REQUIRED. What form must be filled in, by whom, and sent to whom is the data I am seeking.

I think many people don't actually see the doctor face to face after the first 31 days, despite the regulation. Many people never, ever have a face to face with the sleep specialist. Your PCP may be sufficient, if he knows how to document properly. The NP may be enough. Call your DME provider and see if the proper paperwork has been done or how to get it done.

If you MUST go back just to document compliance, I'd just suck it up this one last time. Better than losing your machine. After that you can dump them if you feel that strongly.

[Photomatt]

Thanks, Jankintz, for your reply, that document was very helpful. I think I will call my DME since it appears that they are the ones who have to communicate when requesting funds from Medicare.

[cpapquuen1]

It can be any medical professional. All you need is phyisician noted from the day of your visit that state that you have using the equipment > 4 hrs per night and are benefiting from therapy.

[provider]

Here is the LCD update released in April by Medicare: http://www.ngsmedicare.com/PRINT.aspx?DOCID=21846

I hope that helps.

[akcpapguy]

Photomatt,

Here are the links you are looking for plus the links for the RAD policy and Oxygen.


CPAP https://www.noridianmedicare.com/dme/co ... _apnea.htm


RAD https://www.noridianmedicare.com/dme/co ... evices.htm


Oxygen https://www.noridianmedicare.com/dme/co ... pment.html


Just a general FYI for everyone using Medicare for PAP equipment, there are different criteria under the different policies for Bi-Level usage requirements. Which policy you use to determine usage requirements depends on your diagnosis, if you have a diagnosis of OSA you would use the CPAP policy, if you have any qualifying diagnosis other than OSA you use the RAD policy usage requirements. Note: This is only for people who are prescribed a Bi-Level machine.

[cpapworld]

Cpap guidlines are the patient must used the device for at least 4 hours a day for 30 consecutive days.
They must also have a face to face visit with the doctor of their choice no sooner than the 30-31 day but this visit must take place between the 31-90th day. during this period their download(cpap reading) must show 70% or better.

Rule vary depending when the patient starting using cpap meaning the year and whether or not they came from a commercial insurance.

[packitin]

I'm still a little confused. What about a person on Medicare who has had the machine for, say, 3 or 4 years. He/she will be eligible for a new machine in another year or so. Assume that the person has been using the machine on and off, and has let the average hours lapse to around 3.5 to 3.9 hours. (occasionally there may be gusts of up to 5 or 6 hour averages) Assume that he/she is still making regular visits to the sleep doc, has discussed the situation with the doc, whereupon the doc has tried various prescriptions, suggestions, etc. and the patient still has not been able to keep up the 4 hr average. Will a new machine still be prescribed to the patient. In other words, the patient is a "cpap failure". (there are quite a few of us around like this)

Also, I ask this purely out of curiosity, has anyone ever heard of anyone losing their cpap machine because of noncompliance. I haven't, although at my age I haven't heard of a lot of things, not to mention quite a few things that I've forgotten. (I don't get around that much, anyway). Forgive me, I can't quite seem to perceive of the situation where this might happen.....

Its late. The doorbell rings. Two men emerge from a dark panel truck, wearing assault outfits. "o.k. Mr. ******, we're sorry to tell you this. We are here to pick up your cpap machine. Now, we can do this peacefully, or we can do it hard way, its up to you. Now, will you please show us to your bedroom......"
(I'm sorry, I've been watching too much t.v.)

[Slinky]

Said patient should find another doctor who has the smarts to script a more advanced PAP when patient has failed PAP so miserably w/CPAP (an APAP "is" a CPAP!). Duh!

[Physician]

Here is the LCD update released in April by Medicare: http://www.ngsmedicare.com/PRINT.aspx?DOCID=21846

I hope that helps.

Doesn't help. Bad link.