Medicare coverage for xpap - questions ???

[snardo]

My DME is pretty open with me. She said her cost on this machine is around $3500. Doc K. said it would be around $100 a month rental on them. After 13 months, it is yours.

There's your markup. Her cost is about $3500 and Medicare will pay over $7,500 for the machine over the course of 13 months. That's NOT counting a humidifier! Jeff, it sounds like at least you're getting good care from your DME.

I really don't mean to hijack this thread into a political discussion but allow me a brief observation:
Medicare (i.e. the gubmint) will pay $7500 for something that you can buy through the free market for under $1000 (see CPAP.com for actual numbers).

Is it any wonder that the US government is drowning in a sea of red ink fueled by entitlement programs like Medicare? Not saying Medicare is a bad thing, but perhaps similar ends could be achieved by more efficient means.

Now back to your regular program.

[Pugsy]

I really don't mean to hijack this thread into a political discussion but allow me a brief observation:
Medicare (i.e. the gubmint) will pay $7500 for something that you can buy through the free market for under $1000 (see CPAP.com for actual numbers).

Apples to oranges comparison in this instance.
OP will be getting ASV type of machine. Much more complicated than run of the mill cpap machine that is offered for less than $1000 online. ASV types of machines retail for closer to $6000 online. Actual discounted price may be lower but still well above $4000.

[idamtnboy]

http://www.cms.gov/manuals/downloads/clm104c20.pdf

Your info is completely wrong and outdated. No 10 month letter, no 15 month rental, and no service contract. Everything is a capped 13-month rental. There are many more requirements for bilevels than cpap. As the level of bipap increases (w/back rate, ASV) so do the requirements. For CMS to continue renting a cpap, bilevel, etc. past the initial 90 day period, the dme must demonstrate compliance and that the patient has followed up withe the prescribing physician AND he/she has documented that the patient is using the device and is benefiting from it.

Please provide a link to the pertinent information on the Medicare web site to substantiate your comment. The revision number and date of the manual I link to above is Rev. 1961, 04-30-10, and is the one linked to on the page for DME suppliers, http://www.cms.gov/center/dme.asp.

Are you by chance thinking about the Competitive Bidding Program that Medicare has going in certain parts of the country, or to a Medicare Advantage plan provision? If so, then the rental/purchase provisions may be different. The above info I quote is for original Medicare coverage.

Take a look at document http://www.cms.gov/DMEPOSFeeSched/Downl ... S1167F.pdf. It's the federal law concerning newer xPAP devices being covered by Medicare. At the beginning is this paragraph.

SUMMARY: This final rule clarifies that respiratory assist devices with bi-level capability and a backup rate must be paid as capped rental items of durable medical equipment (DME) under the Medicare program and not paid as items requiring frequent and substantial servicing (FSS), as defined in section 1834(a)(3) of the Social Security Act.

Navigating through the Medicare.gov web site is damned complicated, but I can do it reasonably well. Please make sure you are absolutely sure about what you are saying before you tell me I am wrong. If I'm wrong, I'm wrong, and have no problem whatever acknowledging it, as long as you can unequivocally prove it. In this case we are sharing facts, not opinions.

[PAPpaw]

Try http://www.medicarenhic.com/dme/medical ... rent.shtml. This is where the MC guidelines for my DME are located. This is for region A. There is a different set of guidelines for BiPAP with a backup rate. Could possibly be different depending on where you live though.

[idamtnboy]

Try http://www.medicarenhic.com/dme/medical ... rent.shtml. This is where the MC guidelines for my DME are located. This is for region A. There is a different set of guidelines for BiPAP with a backup rate. Could possibly be different depending on where you live though.

I found the info regarding bi-level machines in a document regarding common billing errors. It has the same info as the document you link to. It appears that it is national criteria, not just for the region you mention. Interestingly though, I cannot find any discussion of bi-level CPAPs in the National Coverage Determination Manual, which is the bible for what is and is not covered by Medicare. Criteria for coverage of CPAP machines is in the manual, but not bi-level machines. I've sent an inquiry to Medicare asking about the omission.

So, in case anyone is wondering, the comments above regarding the fact that a CPAP (which includes VPAP) must fail to provide adequate therapy for the patients OSA condition, are correct. You cannot just move up from an E0601 category machine to an E0470 machine and have it paid for without documented need.

[Janknitz]

I found it here: http://www.cms.gov/medicare-coverage-da ... d-details. Although this is for my local coverage area, I believe it is the same criteria in every LCD.

It says:

INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.


I.An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met:


A.The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.


B.The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):
1.The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,

2.The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
a.Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

b.Hypertension, ischemic heart disease, or history of stroke.
C.The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.


II.An E0470 device is covered for those patients with OSA who meet criteria A-C above, in addition to criterion D


D.An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.

Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).

If E0470 is billed for a patient with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.

A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary.

If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test.

If an E0601 device has been used for more than 3 months and the patient is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin for use of the E0470.

Coverage, coding and documentation requirements for the use of the E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) and Policy Article (PA).

[idamtnboy]

I found it here: http://www.cms.gov/medicare-coverage-da ... d-details. Although this is for my local coverage area, I believe it is the same criteria in every LCD.

OK, I got it figured out. When there is no National Coverage Determination (NCD) for an item the Medicare contractors develop the coverage criteria. See the following quote from the link you give. Bold is mine.

Information about LCDs and LCD Challenges

Section 522 of the Benefits Improvement and Protection Act (BIPA) defines an LCD as a decision by a fiscal intermediary (FI) or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis in accordance with Section 1862(a)(1)(A) of the Social Security Act (e.g., a determination as to whether the service or item is reasonable and necessary).

FIs, Carriers, and Medicare Administrative Contractors (MACs) are Medicare contractors that develop and/or adopt LCDs. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD. The guidelines for LCD development are provided in Chapter 13 of the Medicare Program Integrity Manual.

A local policy may consist of two separate, though closely related documents: the LCD and an associated article. The LCD only contains reasonable and necessary language. Any non-reasonable and necessary language a Medicare contractor wishes to communicate to providers may be done through the article. At the end of an LCD that has an associated article, there is a link to the related article and vice versa.

So, this shows that not every aspect of the Government operated medical care system is determined by bureaucrats. In the case of LCDs coverage is determined by a private contractor! Just what the anti-PPACA crowd wants!

[avi123]

See more on Medicare Coverage Guidelines

here:



http://www.lakesidepress.com/CPAP/CPAP.htm

[idamtnboy]

Jan, I am not sure that the ASV machine is covered under the above. See definitions here:

Medicare Coverage of XPAPS and accessories at my DME

The item fourth from the bottom in the list is the Medicare definition of an ASV. The Resmed product sheet dated April 2011 lists the S9 ASV as code E0471.

[mcdover]

http://www.cms.gov/manuals/downloads/clm104c20.pdf

Your info is completely wrong and outdated. No 10 month letter, no 15 month rental, and no service contract. Everything is a capped 13-month rental. There are many more requirements for bilevels than cpap. As the level of bipap increases (w/back rate, ASV) so do the requirements. For CMS to continue renting a cpap, bilevel, etc. past the initial 90 day period, the dme must demonstrate compliance and that the patient has followed up withe the prescribing physician AND he/she has documented that the patient is using the device and is benefiting from it.

Please provide a link to the pertinent information on the Medicare web site to substantiate your comment. The revision number and date of the manual I link to above is Rev. 1961, 04-30-10, and is the one linked to on the page for DME suppliers, http://www.cms.gov/center/dme.asp.

Are you by chance thinking about the Competitive Bidding Program that Medicare has going in certain parts of the country, or to a Medicare Advantage plan provision? If so, then the rental/purchase provisions may be different. The above info I quote is for original Medicare coverage.

Take a look at document http://www.cms.gov/DMEPOSFeeSched/Downl ... S1167F.pdf. It's the federal law concerning newer xPAP devices being covered by Medicare. At the beginning is this paragraph.

SUMMARY: This final rule clarifies that respiratory assist devices with bi-level capability and a backup rate must be paid as capped rental items of durable medical equipment (DME) under the Medicare program and not paid as items requiring frequent and substantial servicing (FSS), as defined in section 1834(a)(3) of the Social Security Act.

Navigating through the Medicare.gov web site is damned complicated, but I can do it reasonably well. Please make sure you are absolutely sure about what you are saying before you tell me I am wrong. If I'm wrong, I'm wrong, and have no problem whatever acknowledging it, as long as you can unequivocally prove it. In this case we are sharing facts, not opinions.

I file Medicare, along with countless other insurance company claims, on a daily basis, and I assure you that you are completely, 100% wrong about the criteria for CPAP/BiLevel coverage. The one thing that I find extremely wrong with this forum, is people who "think" they know what they are talking about, giving advice to others who are seeking help.

[mcdover]

Any bilevel that has the capability of giving a backup respiratory rate, is classified by CMS as an E0471. The criteria of coverage for an E0471 can be found here: http://www.cignagovernmentservices.com/ ... t_RAD2.pdf

Again, there is no rental past 13 months, no 10 month letter, and certainly, no service contract. If you receive a CPAP, BiLevel, or Bilevel with a backup rate, the rental is capped at 13 months. Documentation and proof of compliance AND benefit are required for CMS to continue paying past the initial 90 days.

[idamtnboy]

Again, there is no rental past 13 months, no 10 month letter, and certainly, no service contract. If you receive a CPAP, BiLevel, or Bilevel with a backup rate, the rental is capped at 13 months. Documentation and proof of compliance AND benefit are required for CMS to continue paying past the initial 90 days.

It looks like that is the case in your region, or whatever Jurisdiction C refers to, for Medicare claims processed by Cigna. In the publication http://www.cignagovernmentservices.com/ ... /Chpt5.pdf, Section 5, page 4, it does state that for claims after Jan 1, 2006 capped rentals are for 13 months. But right under the heading for that section it references the CMS Manual System section I link to above. The CMS Manual System does clearly have the requirement for the 10, 13, and 15 month scenario I discuss above. There absolutely is a conflict between the CMS manual and the Cigna Government Services document.

Apparently this is a case where under the provisions of the Medicare modernization bill, or whatever it was called, of a few years ago, the contractors handling the claims processing for Medicare claims can establish criteria and rules that override the top level Medicare rules. Whether every CMS processor in the country has adopted the same 13 month rule as Cigna, I don't know. If they have, then the 10, 13, and 15 month provisions do not apply.

So, the upshot is we are both correct. I am correct in that the current Medicare claims processing manual requires that the 10, 13, and 15 month provisions apply to capped rentals. You are correct in that the actual procedure implemented by the claims processing contractors has done away with the 10 and 15 month provisions. I would have appreciated it if you had mentioned in your earlier post that Medicare contractors have the authority to override the top level Medicare rules rather than lambasting me as not knowing what I'm talking about. As it is, I discovered by my own efforts that the conflict in our statements have their basis in two levels of regulation which happen to conflict with each other.

[Janknitz]

"So, this shows that not every aspect of the Government operated medical care system is determined by bureaucrats."

Though the general public may not be aware of it, this has ALWAYS been the case with Medicare.

[mcdover]

Again, there is no rental past 13 months, no 10 month letter, and certainly, no service contract. If you receive a CPAP, BiLevel, or Bilevel with a backup rate, the rental is capped at 13 months. Documentation and proof of compliance AND benefit are required for CMS to continue paying past the initial 90 days.

It looks like that is the case in your region, or whatever Jurisdiction C refers to, for Medicare claims processed by Cigna. In the publication http://www.cignagovernmentservices.com/ ... /Chpt5.pdf, Section 5, page 4, it does state that for claims after Jan 1, 2006 capped rentals are for 13 months. But right under the heading for that section it references the CMS Manual System section I link to above. The CMS Manual System does clearly have the requirement for the 10, 13, and 15 month scenario I discuss above. There absolutely is a conflict between the CMS manual and the Cigna Government Services document.

Apparently this is a case where under the provisions of the Medicare modernization bill, or whatever it was called, of a few years ago, the contractors handling the claims processing for Medicare claims can establish criteria and rules that override the top level Medicare rules. Whether every CMS processor in the country has adopted the same 13 month rule as Cigna, I don't know. If they have, then the 10, 13, and 15 month provisions do not apply.

So, the upshot is we are both correct. I am correct in that the current Medicare claims processing manual requires that the 10, 13, and 15 month provisions apply to capped rentals. You are correct in that the actual procedure implemented by the claims processing contractors has done away with the 10 and 15 month provisions. I would have appreciated it if you had mentioned in your earlier post that Medicare contractors have the authority to override the top level Medicare rules rather than lambasting me as not knowing what I'm talking about. As it is, I discovered by my own efforts that the conflict in our statements have their basis in two levels of regulation which happen to conflict with each other.

No, you are completely incorrect. One more time, there is no rental past 13 months, no 10 month letter, and certainly, no service contract. Not in region c, a, b, x, z........ The criteria for coverage is NATIONAL and set by CMS. We are not both correct. You are 100% wrong if you believe that CMS will rent a CPAP, BiLevel, with or without a BR, longer than 13 months. Doesn't matter if you live in Key West or Anchorage, the criteria for coverage is the same and the rental is capped at 13 months.

[avi123]

I see this at my DME in NC:

How does Medicare pay for and allow you to use the equipment?

1.Typically there are four ways Medicare will pay for a covered item:

Purchase it outright, then the equipment belongs to you,

Rent it continuously until it is no longer needed, or

Consider it a “capped” rental in which Medicare will rent the item for a total of 13 months and consider the item purchased after having made 13 payments.
Medicare will not allow you to purchase these items outright (even if you think you will need it for a long period of time).
This is to allow you to spread out your coinsurance instead of paying in one lump sum.

It also protects the Medicare program from paying too much should your needs change earlier than expected.
If you have oxygen therapy, Medicare will make rental payments for a total of 36 months during which time this fee covers all service and accessories.

Beyond the 36 months (for a period of 2 additional years), Medicare will limit payments to a small fee for monthly gas or liquid contents and a limited service fee to check the equipment every six months for equipment that is not covered under warranty.

2.After an item has been purchased for you, you will be responsible for calling your provider anytime that item needs to be serviced or repaired. In cases where you own the equipment and Medicare considers it necessary, Medicare may pay for a portion of repairs, labor, replacement parts and for temporary loaner equipment to use during the time your product is in for servicing. All of this is contingent on the fact that you still need the item at the time of repair and continue to meet Medicare’s coverage criteria for the item being repaired.

and


Positive Airway Pressure Devices (CPAPs and Bi-Level Devices for Obstructive Sleep Apnea)

Continuous Positive Airway Pressure (CPAP) Devices are covered only for patients with obstructive sleep apnea (OSA).

You must have an overnight sleep study performed in a sleep laboratory to establish a qualifying diagnosis of Obstructive Sleep Apnea. In March of 2008, home sleep testing was approved as an acceptable means of diagnosing this condition when your physician deems this testing is appropriate.
Medicare will also pay for replacement masks, tubing and other necessary supplies.

After the first three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine. Per Medicare and Private Insurance guidelines, a face-to-face visit with your physician that documents an improvement of your symptoms is required no sooner than 31 days and no later than 91 days from the set-up date. A data report from your sleep equipment which documents that the PAP has been used for at least 4 hours per night on 70% of nights during a 30-day consecutive period is required.

If the CPAP device is not working, or if you cannot tolerate the CPAP machine, your doctor may also try to use a different device called a Bi-Level or a Respiratory Assist Device (RAD), and Medicare can consider this for coverage as well. To switch to a RAD, the physician must document the following 4 items in the patient’s chart:

1.The patient tried but was unsuccessful with attempts to use the CPAP device; and,

2.Multiple interface (mask) options have been tried and the current interface (mask) is most comfortable to the patient; and,

3.The work of exhalation with the current pressure setting of the CPAP prevents the patient from tolerating the therapy; and,

4.Lower pressure settings of the CPAP fail to adequately control the symptoms of Obstructive Sleep Apnea or reduce the AHI/RDI (apneas and hypopneas) to acceptable levels.

Talk with your provider if you are having problems adjusting to the therapy. There are a lot of variations that can make the therapy more comfortable for you.

*****************************************************************
So I assume that if I comply with the above 4 items then I could check with my Doc for switching to a RAD which could be an ASV.

Also, so says the Clinician Manager at my DME:

"Yes—you have to go back to the doctor, he has to document that you are failing cpap and need a new sleep study. In the study, your diagnosis would have to change to central sleep apnea and a RAD device would have to be ordered. The last four items only apply if you switch to a rad device during the first three months of cpap usage. "

Notice that ASV (Adaptive servo-ventilator) devices are not necesserely regarded as CPAPs or BiPAPs. They are more closely related to NIV (Noninvasive) Ventilators.
Their codes could be E0470 and E0471, as described here:

http://www.cignagovernmentservices.com/ ... t_RAD2.pdf