AHI too low for Medicare

As I will qualify for Medicare in a couple of years, I was reading the Medicare cpap guidelines.
The document I was reading stated that Medicare does not cover CPAP if a patient has an untreated AHI of under 15 events.
Does Diabetes or High blood pressure make a difference, or am I just totally screwed?

I think the number is >5 not >15. Mine was under 15 and Medicare covered me.

From the information in this post viewtopic/t54576/viewtopic.php?f=1&t=45 ... 46#p411146 (underlining/bold mine):

A single level continuous positive airway pressure (CPAP) device (E0601) 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 CPAP device and
accessories in the proper use and care of the equipment.

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

It sounds like you meet the qualifications under B.2.a and/or B.2.b, so you should be covered, unless the regulations were changed since October 2009, when that information was posted.

Thank you! I was really freaking out, CPAP makes me feel HUMAN again!
I was trying to figure out how much I would need for bribes--just kidding!

You appear to have a XPAP now, so someone must have said you needed it, I don't think a doctor would say you didn't need it anymore after they got you set up with one. Jim

I'm still on private insurance now--still working.
Just getting my fanny covered for later.

chunkyfrog wrote:I'm still on private insurance now--still working.
Just getting my fanny covered for later.

I don't think anyone really knows what is in store for people who will be on medicare four years from now. There are all kinds of hidden rules and regulations in the health care bill that was passed this year. I'll be on medicare in six years. If there is any money left in medicare it will be spread so thin the government will be telling us we don't need a cpap just go sit in front of a box fan. I am very afraid of our future health care needs.

chunkyfrog wrote:I'm still on private insurance now--still working.
Just getting my fanny covered for later.

Even with "Medicure", you will need money or private health INS to help pay for your healthcare needs. I government free ride, isn't free..... Jim

"Fanny Covers", aisle three at Wal-Mart!

Sorry if this is a dumb question, but does this mean that we have to have another sleep study as soon as eligible for Medicare, in order to continue cpap tx we've had for years before? Or would the first sleep study qualify?

plr66 wrote:Sorry if this is a dumb question, but does this mean that we have to have another sleep study as soon as eligible for Medicare, in order to continue cpap tx we've had for years before? Or would the first sleep study qualify?

no, your existing sleep study will do fine to get supplies paid for (80% anyway)


JeffH

Guest wrote:

plr66 wrote:Sorry if this is a dumb question, but does this mean that we have to have another sleep study as soon as eligible for Medicare, in order to continue cpap tx we've had for years before? Or would the first sleep study qualify?

no, your existing sleep study will do fine to get supplies paid for (80% anyway)


JeffH

Because I am on Disability Retirement I was forced on to Medicare, I did not need a sleep study for Medicare to pay for my Cpap supplies. My machine broke, it was not with in the 5 year time period for replacement, I was less than 3 years old. I needed a new machine being as BCBS FEHB was no longer my primary insurance and Medicare is I needed a new sleep study to receive a new machine.
My prescription was 4 years old at the time. I was able to buy one from Cpap.com with that prescription. I order to get medicare to foot the bill I had to have a sleep study. If my machine would not have broken I would have had no problem getting supplies thru Obamacare.

But who knows what will happen after the next joke they call an election.

plr66 wrote:Sorry if this is a dumb question, but does this mean that we have to have another sleep study as soon as eligible for Medicare, in order to continue cpap tx we've had for years before? Or would the first sleep study qualify?

Medicare has strict guidelines on a PSG. I would say if your current study meets those guidelines it will be fine, if not another PSG will likely be required. Another reason to acquire a copy of your PSG.

For example, during my 1st PSG the diagnostic portion was 109 minutes which was good for CIGNA but Medicare requires a minimum of 120 min. diagnostic portion. 1st nite was a split-study but Even after two nites back to back for a sleep study I didn't get 120 min. Go figure.

I fired that sleep lab when they wanted me to pay for a 3rd PSG in less than 1 yr.

DreamOn wrote:From the information in this post viewtopic/t54576/viewtopic.php?f=1&t=45 ... 46#p411146 (underlining/bold mine):

A single level continuous positive airway pressure (CPAP) device (E0601) is covered for the treatment of
obstructive sleep apnea (OSA) if criteria A - C are met:

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.
It sounds like you meet the qualifications under B.2.a and/or B.2.b, so you should be covered, unless the regulations were changed since October 2009, when that information was posted.

Aren't these the diagnostic criteria for apnea anyway? I thought apnea was diagnosed with an AHI >15, or AHI >5 with impairments in daytime functioning (eg, EDS)?

Patrick A wrote:

Guest wrote:

plr66 wrote:Sorry if this is a dumb question, but does this mean that we have to have another sleep study as soon as eligible for Medicare, in order to continue cpap tx we've had for years before? Or would the first sleep study qualify?

no, your existing sleep study will do fine to get supplies paid for (80% anyway)


JeffH

Because I am on Disability Retirement I was forced on to Medicare, I did not need a sleep study for Medicare to pay for my Cpap supplies. My machine broke, it was not with in the 5 year time period for replacement, I was less than 3 years old. I needed a new machine being as BCBS FEHB was no longer my primary insurance and Medicare is I needed a new sleep study to receive a new machine.
My prescription was 4 years old at the time. I was able to buy one from Cpap.com with that prescription. I order to get medicare to foot the bill I had to have a sleep study. If my machine would not have broken I would have had no problem getting supplies thru Obamacare.

But who knows what will happen after the next joke they call an election.

Things will be looking up, I hear their is a homeless man born in Mexico, waiting for a chance to cross into the U.S. He's a shoe in to run for President of the United States in the next election. He has no valid birth certificate, but that doesn't seem to be required anymore. Jim

Goofproof wrote: He has no valid birth certificate, but that doesn't seem to be required anymore. Jim

That nonsense is getting pretty old.