Medicare requires repeated new split study? After 15 years of cpap use.

I am hearing what seems like crazy things from my sleep Dr about what Medicare requires for equipment and I wanted to check if any of you had this experience (or didn't have to do this).

Short story:
I need to add some O2 to my cpap. I meet the medicare requirements for this - medical conditions = pulmonary hypertension and severe sleep apnea, and oximeter readings above the requirements even on my good nights (way above on the bad nights.
I don't need O2 during the day, just at night while sleeping (oximeter verified).

Sleep Dr said the sleep studies done 15 years ago (when originally diagnosed) did not have me off the cpap for 2 full hours (AHI 91 and so they put me on a cpap at the 60-90 minute mark). Dr said "Medicare requires a sleep study with at least 2 hours of no cpap" before giving any equipment including adding O2 to a cpap.
I said I would not be able to sleep without my cpap so the Dr prescribed Ambian, while saying it will make the sleep apnea worse.
Dr said don't worry, we can give oxygen (but this doesn't do any good if you are not breathing).

I am headed into bypass surgery sometime the next two months (routine testing led to other testing which showed one severe artery blockage and a second one getting bad despite no symptoms, just diagnosed last week). During that surgury they may also fix my poorly functioning heart valve and my persistent afib - both diagnosed 10 years ago but because of sleep apnea, poor success with persistent afib especially when combined with sleep apnea, and my lack of any symptoms, I was put on a "just monitor" path. In last 10 years, there has been no significant changes to heart valve and afib has improved, but with a double bypass needed they may do all 3 areas at once (still being determined).
If afib correction is needed, the interventionist cardiologists said good O2 is a must (e.g. need to resolve the night time O2 drops).

It makes no sense to me that someone with my health (proven severe sleep apnea, pretty bad O2 drops with a cpap and now severe heart problems) should be taken off their cpap for 2 hours and have extreme drops in O2 - that would just stress my heart more and possibly could send me into emergency surgery (vs a well planned out surgery).

Sleep Dr says "Medicare requirements". He said "it will be safe, lab techs will be there", and "we can give you O2" (without the cpap).

I say - if you are not breathing, that O2 won't get inside the body. I asked are you saying the lab techs know how to prevent a heart attack from no O2? He didn't answer that one.
I say there must be exceptions to the general Medicare rule, there are people much sicker than me that need cpaps or O2 (so far sleep Dr won't even check this out).

I said Sleep Dr needed to get cardiologist approval before 2 hours of sleep with no cpap, ambian (so worse apnea), and likely 15 years later more AHIs and without cpap I would have even lower O2 drops then I am having with the cpap. They are holding off colonoscopy despite it being past due and me being high risk and that can be done using a cpap and O2.
I had to push hard twice but sleep Dr did say he reached out to the cardiologist "to explain" - which I think means he is going to "explain medicare rules and why he understands this is a difficult situation but how it has to be done. We are getting our side to the cardiologist so he is prepared when he is contacted to say nope, not medically advisable at this time.

We are with a HMO (only way to see Drs as new patients in the state we moved to, otherwise 3-6 months with a PPO with no meds, no cpap supplies, etc.).
Unfortunately we are struggling to find good Dr care with the HMO. Luckily the cardiologist is in an affiliated medical institution.
Sleep studies are only done in a lab (I think only one in the state, 2 hours away), despite Medicare accepts at home studies also.
There was some kind of a rule change, maybe Jan 1st, where I would have had to do a new sleep study to get a new cpap, but I got one just before that as they rushed it thru in Dec. (My last one was 16 years ago so it might have been a new test very 10 years, I have no idea if it was a new titration study or a new 2 hours with no cpap study, we were not told).
I don't see any new Medicare rule regarding CPAPs for this Jan/Feb timeframe, maybe it is just a Kaiser rule despite the Sleep Dr saying these are Medicare rules.

Question:
1) Has anyone heard of a requirement for a split study ( 2 hours off cpap), even when severe sleep apnea has been proven, in order to get medicare to cover any cpap / o2 concentrator?

2) Did you hear of a change to the requirements starting Jan 2024 (e.g. do all of us have to get a new sleep study with no cpap for 2 hours whenever we get a new cpap or every 10 years or??).

I am seeing a pulmonologist in a week and possibly they would give me an O2 concentrator prescription, but the Sleep Dr has said in Kaiser the sleep department do the nighttime stuff and the pulmonologist does daytime only .. so I don't know if the pulminologist would prescribe O2 for night.
I am also aware that used equipment might be found on craigslist or other sources.
I have contacted Medicare advocacy for my state as they have pulled rabbits out of their hat for me before.
And I am considering trying to escalate this up the Kaiser chain.

Thanks in advance for your input.

----------------------------------------

Internet search info is below. I didn't save the link that said cpap first then with that on and working well determine that O2 use improves patients O2 saturation.

Documentation that Medicare says:
If sleep study has less than 2 hours of no cpap, just extrapolate what they AHIs should be if it was 2 hours long.
This link https://www.cms.gov/medicare-coverage-d ... &NCAId=204
says:
A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:
AHI or RDI greater than or equal to 15 events per hour, or
....
The AHI is equal to the average number of episodes of apnea and hypopnea per hour. The RDI is equal to the average number of respiratory disturbances per hour.
If the AHI or RDI is calculated based on less than two hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing is at least the number of events that would have been required in a two hour period.

This link talks about Medicare covering home use of oxygen, and plain old says if pulminary hypertension is diagnosed (it has been), patient is qualified to have it covered.
https://www.cms.gov/medicare-coverage-d ... ?NCDId=169

Sorry to hear this... yes, I had a similar experience albeit without oxygen or the other medical complications. Just a simple doctor telling me I needed a new study.

viewtopic.php?f=1&t=187847&p=1452289#p1452289

As you can imagine it was torture. I thought I could make it with three Benadryl tablets... not so, in fact it made it worse because it dried my sinuses out painfully. In addition the clinic did not have controlled humidity, the room was very cold and dry. I 'failed' the study, of course... I begged to be let go but they said if I left early I'd be on the hook for the entire expense. Finally they turned me loose at 5am.

Finally got some hose time... machine took me up to 20cm! Turns out when you torture your airway by trying to sleep with AHI 104 it pisses it off, angry and inflamed. I will never willingly put myself through this again. I found later that they had collected enough data to give me a diagnosis of AHI 27... ludicrous. My doctor seemed pleased, told me that was enough for Medicare to approve me. Looking for a new doctor now.

I telephoned both my insurance (United PPO) and Medicare and was told it was entirely up to me and my doctor, that a new sleep study was not required. Now this may have been untrue... often government functionaries remain anonymous and tell you things just to get you off the phone to leave them alone. I'm still working at age 65 so I'm not on Part B yet.

I obtained a split-night titration for CPAP and bi-level next month in a completely different clinic. The tech was knowledgeable and experienced unlike the other lab. I did request Ambien and was provided one by my doctor beforehand. It helped some but they try to get you down by 11pm... I normally go to sleep at 1am... so some time wasted there. I could tell it was helping though I'd really rather have had two of them! Anyway it did help and saved time... but no way it would allow you to 'pass' a split-night study. In that first lab I would have needed professional anesthesia... the snoring from the room next door was thunderous, for one thing.

Contact Medicare and verify what I was told. If they make you do this request more than one Ambien... or take a few stiff drinks before. I was told if I could de-sat to O2 <70% they'd discontinue the torture... I only managed to get to 83% before waking, gasping... of course I've trained myself to not allow this near-death experience. I wore my O2Ring for the first part of the study... after I'd wake gasping it would go off showing <90%... they finally said 'your ring is waking you, take it off'... which I did... which did not help. If you do this turn off the vibratory alarm. This is, in effect, training your body to hate sleep.

Another thing to do is *try this at home* first... I wish I had, could have saved myself the 500$. As it is, I guess I'm no longer in the Severe category! Which is a laugh, as my CPAP titration has gone from 10cm to 13cm and my bi-level is 17/21 PS4... probably put on a hundred pounds, I guess that helped take me down to 27 right?

Gen99, the links you provided show that you are absolutely correct and your sleep doctor is absolutely wrong. Can your primary care physician intervene to get this sorted out? If not, in your place I would escalate the issue rapidly within the Kaiser system.

I'm a Kaiser patient myself, and I just took a look at the website. There's something called a Member Relation group that, among other things, deals with "Grievance and Appeals."

I also found a link that allows the submission of a complaint. I clicked on it, then clicked on "yes" for the question whether this issue was for a Medicare patient. I then got this:

"We’re here to help you get the care you need. Use this form to report an issue with the services or care you’ve received from Kaiser Permanente.

Important:

If you think you or someone you're caring for is having a medical or mental health emergency, call 911 or go to the nearest hospital. Do not attempt to access emergency care through this form.
If you think the issue you’re reporting needs urgent attention, call our Expedited Review department at 1-888-987-7247 (TTY: 711), 8 a.m. to 5:30 p.m., 7 days a week.
As a Kaiser Permanente Medicare health plan member, you have 60 days from the date the service was received to file a grievance.

If you’d like assistance with this form, contact Member Services."

I imagine the phone number would be different for you, but the "Expedited Review department" number for your area sounds like just the ticket.

Gen99 wrote: ↑

Thu Apr 25, 2024 2:31 am

Sleep Dr said the sleep studies done 15 years ago (when originally diagnosed) did not have me off the cpap for 2 full hours (AHI 91 and so they put me on a cpap at the 60-90 minute mark).

I don't believe this is true. Speak directly with Medicare to determine.

I had a PSG in 2004 and had to dx 2hrs for the Original Medicare. So I think this doc has some financial interest in this sleep lab. I also think it is time to find another Sleep Dr. preferably a Pulmonologist.

From what you are saying - you are likely to have a heart attack while sleeping never mind attempting to sleep without your cpap. NWIH NO Way would I stress my heart for this guy.

Oh now I see Kaiser mentioned I won't/don't do Kaiser and will leave it at that. I won't do any HMO either. When moving you are allowed to change to the Original Medicare if no longer covered by your HMO and are Medicare eligible.

Good luck to you.

We heard back from the Medicare advocacy group.
FYI, we highly recommend using them when you need support. They have pulled a rabbit out of their hats previously to get exceptions for Medicare rules (allowed a plan change when not eligible to do so at that time) - and it took a few days vs months of “appeal”.

This is their reply:

Hello.
My team and I have been searching the CMS rules for something different than what you have found, and we have been unsuccessful.
Since part of the issue is that the Dr does not seem to be following your requests, you may benefit from speaking with the Medicare Quality Improvement Organization, KEPRO. They often provide advocacy for situations such as yours.
You can go to their website for more information; https://www.keproqio.com/. Or give them a call at 888-305-6759.

We called this new group, left a message, and should hear back tomorrow.

Yes, please do narc out the greedy doctor, who is apparently hoping for a big kickback,
regardless of whether or not the patient survives the exam.

Thanks everyone for your input.

We are in a HMO because the other choice in our state was waiting for 3-6 months to see any Dr, meaning no cpap supplies, no new cpap machine - it was time, no medicines, and no annual exam and no annual cardiology tests (which found the new heart problems), and no colonoscopy which was due.
There is a severe Dr shortage in our area (unlike our last state where PPOs were our choice).
Unfortunate but what we are dealing with right now - lesser of two evils. I am fortunate my cardiologist is outside of Kaiser (affiliate) or likely the new heart issues would never have been found.

Yes we have run into Drs that insisted a new sleep study was required (and insurance backed this up at the time though later we found it was not needed).
We previously choose Drs who agreed that Oscar results were good enough annd better reflected ant home sleep, and no other sleep studies were done.

Chunkyfrog, I am not sure what your comment is in reference to…..

The medicare advocacy group is volunteers - not part of Medicare or any insurance or medical groups.
They do a great job, but they give advice and previously cut thru red tape. I am very happy they did a thorough check and then pointed us to the people inside Medicare who can override the Dr.

I seem to only have mild apnea compared to some of you, only 83 AHI.
It has been 13+ years since my split night study. 10 years since my Complex apnea study.
I agree that Kaiser is a good place to go to die.

I bought a used Resmed Aircurve ASV last October and my Medicare Advantage plan reimbursed me for 80% of what I paid.

So I do not believe it is a Medicare requirement to have a split night study periodically.

bwexler wrote: ↑

Thu Apr 25, 2024 8:48 pm

I seem to only have mild apnea compared to some of you, only 83 AHI.
It has been 13+ years since my split night study. 10 years since my Complex apnea study.
I agree that Kaiser is a good place to go to die.

I bought a used Resmed Aircurve ASV last October and my Medicare Advantage plan reimbursed me for 80% of what I paid.

So I do not believe it is a Medicare requirement to have a split night study periodically.

I know nothing of medicare, but if I understand the OP correctly, the issue is financing the oxygen supplementation equipment, not the CPAP.

Gen99 wrote: ↑

Thu Apr 25, 2024 2:31 am

I need to add some O2 to my cpap. I meet the medicare requirements for this - medical conditions = pulmonary hypertension and severe sleep apnea, and oximeter readings above the requirements even on my good nights (way above on the bad nights.

My logic says that a full night's oxygen professional oxygen tracking while you're using you CPAP at home should show the need for oxygen supplementation at night.
You don't mention which kind of oximeter verified your need for oxygen during the night - a consumer one or a professional one.
If it was not a professional one, ask your pulmonologist for a night of professional oxygen tracking. Or for that matter, a 24 hours monitoring of your oxygen saturation. On second thought, you may want to ask the pulmonologist for that even if the previous confirmation was by an oximeter from the so called sleep "doctor".

You're right that "oxygen won't get into your lungs if your breathing is obstructed". I wonder if your cardiologist can give you a letter stating how dangerous it would be for you to sleep without CPAP.

The idea that "pulmonologists do day breathing and sleep doctors do night breathing" is absurd beyond words. Even for bureaucracies.

I also have an oxygen concentrator fully paid for by my Medicare Advantage plan.

I know the Advantage plans are supposed to be ripoffs, but mine has stepped up more often than not. When they don't, I thankfully have been able to get what I need and pay out of pocket.

My primary Care Doc has been very cooperative about writing prescription's for what ever I want. Thankfully I want less drugs than he wants me to take.

Ozij, the type of oximeter the patient owns is irrelevant.
They don't know your equipment nor it's history, they want to use their own equipment.
It can be the exact same model as would be sent to the patient (by the Dr / DME / Sleep lab), or even a better quality one but their equipment must be used for official testing.

The oximeter must be sent from one of the places listed above (or done in a sleep lab). Apparently DMEs used to send them (I have a friend where that path was taken years ago), but this doesn't seem allowable by medicare anymore. It must come from the Drs office or a sleep lab, though it can be done "at home".

chunkyfrog wrote: ↑

Thu Apr 25, 2024 5:46 pm

Yes, please do narc out the greedy doctor, who is apparently hoping for a big kickback,
regardless of whether or not the patient survives the exam.

NOT in Kaiser. Kaiser is capitated, which means they get the same amount from Medicare whether they provide a LOT of treatment, and testing or NONE. The only possible "greed" motivation is that Kaiser has perpetual co-pays for DME, there's no capped rentals. So as long as you are a Kaiser Senior Advantage member--possibly for the rest of your life--you will have to pay a monthly 20% rental co-pay for CPAP and an O2 concentrator. But an individual doctor at Kaiser isn't going to profit from that one bit.

If you need oxygen at night, that may be an internal Kaiser requirement in order to cover the oxygen concentrator WITH CPAP. They want to make sure you REALLY need it. It's NOT a Medicare requirement. More likely that Kaiser facility or the Kaiser region OP is in is squeezing the nickels.

And there's been a bit of hyperbole going on here. While Kaiser usually does home studies with a Watch Pat device, your statement that they are requiring a split study means in lab and MONITORED (due to the complexity of your apnea). Clearly if your O2 is tanking, they will put you on CPAP and O2, rather than watching you die or suffer brain damage, even if your two hours isn't up. A split study sounds horrible and unpleasant, but they do have responsibility for you during that test.

Gen99 wrote: ↑

Mon Apr 29, 2024 3:18 pm

Ozij, the type of oximeter the patient owns is irrelevant.

Did you see me mention anything about the oximeter you do or di not own?

ozij wrote: ↑

Thu Apr 25, 2024 9:50 pm

If it was not a professional one, ask your pulmonologist for a night of professional oxygen tracking.

Let me empasise the above: ask your pulmonologist for a night of professional oxygen tracking

ozij wrote: ↑

Thu Apr 25, 2024 9:50 pm

You don't mention which kind of oximeter verified your need for oxygen during the night - a consumer one or a professional one.

So, how was your need for additional oxygen verified? Did you just come to the doctor with your results - regardless of which type of oximeter you used - or did the doctor verify your need for oxygen with equipment s/he supplied?

I agree with ozij.
The complete split night sleep study seems excessive.
Overnight professional oximetry should be sufficient--IMO.