Medicare guidelines for new cpap machine

terry123 · Post by **terry123** » Mon Dec 28, 2020 2:29 pm

I am hoping to replace my present cpap machine that I have used every night for 5 1/2 years. When I was first diagnosed with sleep apnea in 2005, there were no sleep medicine certified physicians and my ENT doctor is the one who ordered the sleep study and has been ordering supplies and machines as needed over these last 15 years. I have always been compliant with usage. However in 2013 I had surgery that had ng tube afterwards so did not use cpap for a few nights. Don’t know if it was that or the potassium being low or a combination that caused me to get atrial fibrillation. After 4 years of dealing with that I finally had a cardiac ablation and have not had afib since..Now I am told my doctor cannot order a new machine because he is not sleep certified and I will have to have a new sleep study with a new doctor. So I will have to sleep without the benefit of a cpap machine in order to do a new sleep study. As sleep apnea is a big risk factor for afib, I think it’s a bad idea. Sorry this so long, but any suggestions from anyone who may have had such a problem?

Pugsy · Post by **Pugsy** » Mon Dec 28, 2020 2:34 pm

Who is telling you that you need a new sleep study?

Were you on Medicare when you got the machine you are now using?

Now I am told my doctor cannot order a new machine because he is not sleep certified and I will have to have a new sleep study with a new doctor.

Medicare itself doesn't require that the doctor ordering equipment be a sleep certified doctor...so that statement is BS.

Medicare won't now automatically replace a machine after 5 years despite it still showing that on the guidelines. More and more Medicare and other insurances are adopting a "will replace only if broken beyond repair" approach.

zonker · Post by **zonker** » Mon Dec 28, 2020 6:05 pm

terry123 wrote: ↑
Mon Dec 28, 2020 2:29 pm
I am hoping to replace my present cpap machine that I have used every night for 5 1/2 years. When I was first diagnosed with sleep apnea in 2005, there were no sleep medicine certified physicians and my ENT doctor is the one who ordered the sleep study and has been ordering supplies and machines as needed over these last 15 years. I have always been compliant with usage. However in 2013 I had surgery that had ng tube afterwards so did not use cpap for a few nights. Don’t know if it was that or the potassium being low or a combination that caused me to get atrial fibrillation. After 4 years of dealing with that I finally had a cardiac ablation and have not had afib since..Now I am told my doctor cannot order a new machine because he is not sleep certified and I will have to have a new sleep study with a new doctor. So I will have to sleep without the benefit of a cpap machine in order to do a new sleep study. As sleep apnea is a big risk factor for afib, I think it’s a bad idea. Sorry this so long, but any suggestions from anyone who may have had such a problem?

is it possible to visit another doctor? as pugsy says, there is no requirement for it to be a sleep doctor. from what i understand, ANY doctor can write a prescription. it could even be a dentist.

good luck!

chunkyfrog · Post by **chunkyfrog** » Mon Dec 28, 2020 6:34 pm

Probably pushing it to ask a vet . . .

My DME considered "too noisy" to be adequate to replace my 5+ year old machine, 17,000+ hours runtime.

LSAT · Post by **LSAT** » Mon Dec 28, 2020 8:40 pm

I have been on Medicare and for my last machine my Primary Care Doctor wrote the RX. Who determines what doctors are "sleep specialists". Some are ENTs, Pulmonary Specialists, Neurologist...Most have Sleep as a secondary specialty. Find out what DMEs are in your insurance network and walk away from this one.

SleepGeek · Post by **SleepGeek** » Tue Dec 29, 2020 9:50 am

My online DME had my machine replaced after 5yrs w/o another study. The key was current followups with my sleep doc - I think they schedule them every 6mos but it has to be face to face (or it did). Mostly Medicare wants the doc to have proof you are using the equipment even to get supplies. So the doc schedules whenever insurance will pay again.

Okie bipap · Post by **Okie bipap** » Tue Dec 29, 2020 10:02 am

We met with the nurse practitioner at the sleep clinic last week and she mentioned my machine is now five years old. She asked me if I wanted a prescription for a new machine. I told her no, I will wait until mine quits. I have a spare to use when my primary machine dies.

klm49 · Post by **klm49** » Tue Dec 29, 2020 10:13 am

I ask my PCP about an RX for Sleep Apnea equipment/supplies, she flat out told me she didn't know enough about it to do it. My regular Sleep Dr. I see once a year has told me I likely need a Bi-pap instead of my APAP but would have to wait till my machine was 5 yrs. old. If she gets me a Bi-pap this year I would expect and would want to at least be retitrated for it by them.

ChicagoGranny · Post by **ChicagoGranny** » Tue Dec 29, 2020 4:06 pm

klm49 wrote: ↑
Tue Dec 29, 2020 10:13 am
I ask my PCP about an RX for Sleep Apnea equipment/supplies, she flat out told me she didn't know enough about it to do it.

My PCP is patient-centered. He gladly writes Rxs for whatever I need. The first time, I told him what to write.

terry123 wrote: ↑
Mon Dec 28, 2020 2:29 pm
I am told my doctor cannot order a new machine because he is not sleep certified and I will have to have a new sleep study with a new doctor.

That sounds like something from a poorly informed DME. Many of them are poorly informed.

zorki1c · Post by **zorki1c** » Tue Dec 29, 2020 4:59 pm

When I changed health care plans and wanted to replace a five year old machine I had to get a new sleep test. But I got a new machine even though my old one still works. Kept it as a backup

ChicagoGranny · Post by **ChicagoGranny** » Tue Dec 29, 2020 5:06 pm

zorki1c wrote: ↑
Tue Dec 29, 2020 4:59 pm
When I changed health care plans and wanted to replace a five year old machine I had to get a new sleep test.

I don't doubt that you underwent a new sleep study because someone told you it was necessary. I do doubt that it was necessary. The right questions need to be addressed to the right people.

Pugsy · Post by **Pugsy** » Tue Dec 29, 2020 6:06 pm

ChicagoGranny wrote: ↑
Tue Dec 29, 2020 5:06 pm

zorki1c wrote: ↑
Tue Dec 29, 2020 4:59 pm
When I changed health care plans and wanted to replace a five year old machine I had to get a new sleep test.
I don't doubt that you underwent a new sleep study because someone told you it was necessary. I do doubt that it was necessary. The right questions need to be addressed to the right people.

Amen.

We as consumers need to quit treating DMEs and doctors like they walk on water and aren't ever either misinformed or simply crooked liars. We are way too trusting.

We both know if Medicare has already paid for one machine that they won't need or really want to pay for another sleep study because they already have proof of need. Now exceptions might happen if someone is needing to change a type of machine...like going from cpap to ASV or some other specialty machine...but to just get another cpap like the one that Medicare paid for already...Medicare doesn't ever require another sleep study.

Grumpy48 · Post by **Grumpy48** » Tue Dec 29, 2020 6:28 pm

I never saw the prescript for my CPAP, but I believe my PCP only transcribed the information from the sleep study results to fill out the prescript order as it was quite straight forward and only specified an Auto CPAP with heated humidity, the pressure setting, and best fit mask. Without the sleep study recommendation he likely couldn't have filled out the prescript. I never saw a sleep doctor at any point in time either prior to the sleep study or after, only the technician that performed the the two sleep studies. A sleep doctor did review the results and made the recommendations, but otherwise my PCP was the main contact person for the whole experience. I've been on CPAP for a little less than a year, so I don't know what may be required in the future if I should need replacement equipment.

An excerpt from my DME's website regarding Medicare requirements....
The role of the physician with respect to home medical equipment:
- Every item billed to Medicare requires a physician’s order or a special form called a Certificate of Medical Necessity (CMN), and sometimes additional documentation will be required such as copies of office visit notes from prior visits with your physician or healthcare provider or copies of test results relevant to the prescription of your medical equipment.
- Nurse Practitioners, Physician Assistants, Interns, Residents and Clinical Nurse Specialists can also order medical equipment and sign CMNs when they are treating you.
- All physicians and healthcare providers have the right to refuse to complete documentation for equipment they did not order, so make sure you consult with your physician or healthcare provider about your need for medical equipment or supplies before requesting an item from a supplier.
- For every new item prescribed by your physician or healthcare provider, you should have a recent office visit that documents the reasons for ordering the equipment and products. Many items will now require you to have an in-person office visit with your doctor or healthcare provider to discuss the need and justification for the prescription of medical equipment before a supplier can fill those orders.

This 'Recommendations' from my sleep study is what I believe my PCP used when filling out the prescript for the order. Very little to it and easy for my PCP to copy.

SleepGeek · Post by **SleepGeek** » Tue Dec 29, 2020 8:24 pm

terry123 wrote: ↑
Mon Dec 28, 2020 2:29 pm
I am hoping to replace my present cpap machine that I have used every night for 5 1/2 years. When I was first diagnosed with sleep apnea in 2005, there were no sleep medicine certified physicians and my ENT doctor is the one who ordered the sleep study and has been ordering supplies and machines as needed over these last 15 years. I have always been compliant with usage. However in 2013 I had surgery that had ng tube afterwards so did not use cpap for a few nights. Don’t know if it was that or the potassium being low or a combination that caused me to get atrial fibrillation. After 4 years of dealing with that I finally had a cardiac ablation and have not had afib since..Now I am told my doctor cannot order a new machine because he is not sleep certified and I will have to have a new sleep study with a new doctor. So I will have to sleep without the benefit of a cpap machine in order to do a new sleep study. As sleep apnea is a big risk factor for afib, I think it’s a bad idea. Sorry this so long, but any suggestions from anyone who may have had such a problem?

I had a PCP who refused to write me a script for supplies or a cpap. I wasn't sure if he just didn't know what to do or was being a dink but ....
I promptly found a Pulmonary doc who was the director of the sleep lab at the local hospital. We hit it off great she loved it when I would bring in a print out of my results cuz I already fired Apria and American Home Care and was using an online DME so I printed out my stats first with Encore then with Oscar. She liked my stats and always asked if she could show them when she teaches, np. By then Medicare was requiring face to face and documentation the patient is using AND benefiting from the use of cpap equipment. The Oscar printouts document use and her notes document the benefits.

So I second, 3rd, & 4th find a new doc, if its a sleep doc fine but find someone who is not afraid to help and not afraid of Medicare. How about your ENT or Heart Doc?

klm49 · Post by **klm49** » Wed Dec 30, 2020 8:42 am

ChicagoGranny wrote: ↑
Tue Dec 29, 2020 4:06 pm

klm49 wrote: ↑
Tue Dec 29, 2020 10:13 am
I ask my PCP about an RX for Sleep Apnea equipment/supplies, she flat out told me she didn't know enough about it to do it.
My PCP is patient-centered. He gladly writes Rxs for whatever I need. The first time, I told him what to write.

Thanks but I will stick with using my Sleep Dr., she has been board certified in Sleep Medicine whereas my PCP has not.

Medicare guidelines for new cpap machine

Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

Re: Medicare guidelines for new cpap machine

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