Medicare Coverage for an Fully Data Capable CPap

I am new to the sleep apnea world. I just got my machine yesterday, but found out its not fully data capable. The machine I have is Rhilips Respironics Remstar SE. I called the DME back and they told me they would have to check to see if Medicare covers the cost of an fully data capable machine. She informed me she would have to call me back. I ask how long it would be. They told me it could be a few days. I have read from other forums Medicare will pay for one because it is the same billing code, but these posts are back from 2010. Its 2013 now. Does Medicare still pay for an fully data capable CPap? Also, since I just got the machine what should I do? I don't want to be stuck with an basic cpap that can't do nothing but record how long you have had it on. I want to keep an eye one treatment. I also have Medicaid that pays for the deductibles for Medicare.

I think the DME is hoping you forget about it and go away. I would be willing to bet my last dollar (and I dont have many) that Medicare will pay for a data capable machine. They just dont want to GIVE you a data capable machine because they will make less profit. Call Medicare yourself and verify that they pay by code and that they do not care what kind of machine you get. If you have to, go back to your doctor and have him specify the machine you want on a prescription, and make sure you get that prescription IN PERSON. They can fax it to the DME, but make sure you get a copy. Good luck and let us know how it goes!

I have read that Medicare starts out on rental basis. Take it back to the DME and tell them it is not acceptable. Leave it with them.

If they don't want to supply the right machine, take your prescription to another DME.

Make sure you know the exact model numbers that are acceptable and check the number on the machine. The numbering system is confusing - I don't know them myself - and you have to be very careful.

Call Medicare yourself and verify that they pay by code and that they do not care what kind of machine you get.

Is that really necessary or even possible?

Aren't there 65+ members here who can answer this?

luke1985 wrote:Does Medicare still pay for an fully data capable CPap?

Yes, Medicare still pays by HCPCS billing code which doesn't distinguish between data or non data machine.
That part hasn't changed.

All cpap/apap machines are billed under E0601 billing code...from the basic brick no data to the full data apap/cpap model.
They don't do model names or brands or data vs no data or partial data.

Basically there are 3 codes for xpap machines
E0601 for the cpap/apap machines...it includes apap mode available machines because an APAP machine is a cpap machine with auto adjusting pressure modes available. It's still a single pressure machine. This would be the type of machine you are going to be using.

E0470 for a bilevel pressure machine which offers 2 separate pressures for inhale and exhale.

E0471 for a bilevel pressure machine that has special features for additional treatment of central apneas.

Know your models..read this especially the part down at the bottom of the page.
http://maskarrayed.wordpress.com/

If the DME tells you that Medicare won't pay for a full efficacy data machine then they are lying to you. They just want to make more money because Medicare pays the same amount for all E0601 machines and the bricks cost them less so they make more money.
If your DME won't give you what you want....start calling around for other DMEs who are Medicare providers and find one that will supply what you want. There are DMEs who will do just that and some are really good because they supply full data machines as a matter of standard practice.
Read this too...
http://maskarrayed.wordpress.com/what-y ... me-part-i/

Yes its possible to call Medicare and get answers.

With the new Medicare competitive bidding thing being implemented...I am afraid that we are going to see more bricks and more DMEs who are really stubborn about supplying the full data machines because they won the bid with a really low price and there isn't enough profit margin with the cost of a full data machine and what they are contracted to charge Medicare.

I suspect that it will get harder and harder for Medicare cpap users to find a DME that will provide full data machines in the areas where competitive bidding has been implemented.
It's going to be easier in the areas where competitive bidding hasn't taken hold yet.

I don't know enough about online providers who have won a bid to offer any ideas on the feasibility of using an online provider and what they might supply. There's nothing stopping a person from getting a machine elsewhere and using local DME for masks or other supplies though.

Okay I check the website out. It says Medicare will cover any E0601 machine. How can I arugue that with dme? Should I give them a chance and give them a few days to call me back? I have been told they will call me back in a few days. I want to get this exchange before I can't. I know its a rental? What machine should I go with? Please help. My pressure is set at 11 and my ahi was around 14.
Thanks please help argue with them. Or should I just return it and tell them to give me a call when they can verify I can get a fully data capable machine, even though I know I can. I need your guys help, I don't want to be misled by DME. Which at this point, I know I am. I have medicare Part A and B. I called medicare and they just said an cpap machine is covered the first three months through rental. Just let you know I did use the machine for 10 hours last night, and I don't feel exhausted, and my mood is a little bit better. I just got to get used to the mask. I woke up several times through out the night.

Just talk to dme. I told them I talk to medicare and any E0601 machine is covered. She told me she was going to talk to the owner that comes in later today. She seemed like I knew what I was talking about. I hope that works. Anymore tips to try with DME when I talk to the owner?

I think you are doing really well!!!
Others can advise you best on what kind of machine to get. Personally I like the one I have, which is the ResMed S9 Autoset. It is fully data capable and very quiet. Looks nice, too. The name AUTOSET is on the top by the turn on knob. AVOID the ESCAPE.

Others have Respironics 560 or higher and like them as well.

Good luck and just leave the machine, walk out, and let them know you will be going elsewhere if they cant give you what you want.

Stand firm with DME. Explain how in the world can a person be expected to evaluate their therapy if they can't even evaluate leaks and if leaks are big it can totally mess with effectiveness. Don't let them tell you that you would wake up with big leaks...I have slept through some monumental leaks and I am not the only one.
Don't dwell too much on the other data..just zero in on leaks...any machine that offers leaks will also offer the other data.
Just say you have your mind made up and if they don't want to give you what you want and feel is necessary so that you can make sure you are getting the best therapy possible...that you will go find someone who will. Be firm...

I don't know if the humidifier that goes with the Remstar SE that you have will work with the other PR S1 machines...if it will then I would stick with the PR System One full data machines....either the model 460 or the 560...that way you won't have to buy another humidifier. With Medicare they normally buy the humidifier immediately and the blower unit goes under the rent to own thing.
The DME will know if the humidifier you have will work with the full data model PR S1 machines.
The PR System One models 460 or 560...great machines and will serve you well. Software is easy to get..I can help you there or you can use SleepyHead...see my signature line for SleepyHead information.

You will stand a better chance of getting a full data Respironics machine than you will with a ResMed machine. If the DME is dispensing the Remstar SE then they likely have a Respironics contract....ResMed machines cost more at the wholesale level...and no, they aren't "better".
The PR S1 model 460 is going to function like what you have now in terms of pressure delivery.
The PR S1 model 560 offers the same function that you have now and also auto adjusting pressure delivery...so it's like 2 machines in one. It isn't the end of the world if you can't get a 560 machine...the 460 offers some limited auto adjusting pressures and people can still get great therapy with fixed cpap pressures.
APAPs are nice and if you can get one then that is a bonus but not the end of the world if you can't.

I recently went back onto APAP and I am on Medicare Disability (not for OSA). The DME gave me a Resmed S9 Autoset with the Climate controlled hose. They said that Medicare starts out renting the APAP and then buys it later, I think a lot of people do not stay with the treatment and had the machines back.

luke1985 wrote:Just talk to dme. I told them I talk to medicare and any E0601 machine is covered. She told me she was going to talk to the owner that comes in later today. She seemed like I knew what I was talking about. I hope that works. Anymore tips to try with DME when I talk to the owner?

Comment,

Why don't you get registered and enter your location. Posters might know nice DMEs near new. Your Doc also can say a word to a DME, unless he/she don't want you to know about setting your machine. There are many of those too. Ask your Doc (or office) why your Sleep Study results were sent to a DME that wouldn't provide you with data output capable machine.

Okay I registered. If anyone knows nice DME around Athens, Ohio 45740, let me know. I have already called twice to DME. Should I go ahead and call later today after 2:15 p.m.? This way I can talk to her again. She said she would talk to him today when he came in later today? I know brothering to much, will be bad. But I also don't want them to think I will forget about this major problem. I need to check my leak loss often so I know I get an good session. If I can't look at that then I don't know how much sessions are going, which means the machine will not be helping me. This is some of the stuff I am thinking of mentioning if they want to try to play dumb. I can't belive DME can do this. Its not fun for anyone, including others out there, to have to go through this much hassle to get a machine that have leak loss or fully datable capable.

Call the DME and yell at the Resp therapist. Tell them the machine is making noise or something and you want a new one, and you won't take the same make or model as a replacement. Tell them you want X brand and Y model. You may actually first need to get your MD involved to intervene.

The problem is that if the DME filled the Rx as written, and the MD had simply written "CPAP" then they really can give you anything they want. The cheapest CPAP they stock is OK. If the Rx said a specific make and model and they didn't provide it, then they are the ones who messed up and have to fix it. Otherwise it's really up to their discretion to replace it or not.

Unfortunately so many people, regardless of insurance, find themselves in this spot after they get their machines and have buyer's remorse....

At the end of the day, even if you get stuck with that machine, it's not the end of the world. People have been using them for decades. Is it ideal? No. Is it horrible? No. As long as you had a proper titration study, and the machine is set as recommended, you should be fine. You may have to go in for more sleep studies to keep tabs on your progress, but it's not the end of the world.