Medicare and 2nd machine

[AirSign]

About getting my new APAP machine . . .

Just got a call from Dr's office that DME wants a statement from them that CPAP is benefitting me.

MD is new -- only saw him once, so nurse said DME says it's OK for me to say that CPAP is benefitting me.

Nurse said this is because of Medicare rules.
If the MD writes the prescription, that's not enough. He also has to certify that the therapy I've been using for 6 years every night is benefitting me?

My first response was to say "well, I'm still alive."

Has anyone else had this required from Medicare for a second machine after 5+ years?

[OpalRose]

About getting my new APAP machine . . .

Just got a call from Dr's office that DME wants a statement from them that CPAP is benefitting me.

MD is new -- only saw him once, so nurse said DME says it's OK for me to say that CPAP is benefitting me.

Nurse said this is because of Medicare rules.
If the MD writes the prescription, that's not enough. He also has to certify that the therapy I've been using for 6 years every night is benefitting me?

My first response was to say "well, I'm still alive."

Has anyone else had this required from Medicare for a second machine after 5+ years?

AirSign,
It sounds logical that Medicare would want a statement from your Doctor. The DME probably has to submit that statement to Medicare.
Even if your Doctor is new, he should be the one to submit this statement to DME.
OpalRose

[justMongo]

Medicare is pulling out the medical necessity card to the detriment of beneficiaries.
After over 10 years of testing blood glucose 5 times a day, they just denied my order.
I appealed -- they denied. CMS is run by a private contractor, Noridian Systems.
Medicare is immune from legal action -- Noridian is not.
Noridian and their employees can all be sued.

[Clay L]

Medicare required a Doctor - can be a primary care doc does not have to be a sleep doc - to certify that CPAP is benefiting my wife. She got her machine about a year ago. I got my current one several years ago and that was not required then.

The doc said that he had to actually see her, he was willing to just make the certification but Medicare wouldn't accept it. We took a Sleepyhead summary page to show him and he put that in her file.

[zonk]

Hi AirSign

As you have been using your machine "RemStar Plus" for the last 5 years, the machine report compliance data, you can take the machine or/and data card to the doctor so he/she can verify your compliance
My understanding, successful compliance is that you're using the machine at least 4 hours each night 70% of he time or something like that

As for the machine, ask the doctor to write the prescription for the machine of your choice and "dispense as written" to avoid any confusion and end up with the wrong machine which is something happen quite often, also keep a copy of the prescription for your self, you never know when you might need it

Best of luck

[Mike1953]

Medicare may allow a new machine every 5 years but each time a new machine is issued you have to show the compliance and meet face to face with your Dr. who has to file that it is a benefit to your health. Then you have to meet with him within the 90 days compliance for Medicare to continue to pay for your new machine. Compliance is at least 4 hours each night for 70% of the time during the first 90 days of using a new machine.
Medicare and most private insurers cover scheduled replacements of all mask parts and other supplies (including CPAP machines, but we’ll talk about those in an upcoming blog post). Ask your insurance provider how often it will cover the replacement of each part. Your equipment supplier can answer any questions about this and even help you fill out and process any necessary forms. Based on Medicare coverage, we suggest that you replace:
Every month
• Mask cushions and/or nasal pillows
• CPAP machine filters
Every 3 months
• Mask frame (not including the headgear)
• CPAP tubing
Every 6 months
• Mask headgear
• Chin strap (if applicable)
• Humidifier water tub

[AirSign]

Thanks everyone. I ran out of my allotted number of posts or I would have responded sooner.

Am still waiting for my January titration results.

My new pulmonologist MD is relatively new to the USA, and perhaps has not much experience with Medicare.

As for replacements on everything else to now, my DME has been very conscientious and prompt.

Second night with Wisp went better.

All in all, things seem to be moving in the right direction.

[Homerec130]

Medicare may allow a new machine every 5 years but each time a new machine is issued you have to show the compliance and meet face to face with your Dr. who has to file that it is a benefit to your health. Then you have to meet with him within the 90 days compliance for Medicare to continue to pay for your new machine. Compliance is at least 4 hours each night for 70% of the time during the first 90 days of using a new machine.
Medicare and most private insurers cover scheduled replacements of all mask parts and other supplies (including CPAP machines, but we’ll talk about those in an upcoming blog post). Ask your insurance provider how often it will cover the replacement of each part. Your equipment supplier can answer any questions about this and even help you fill out and process any necessary forms. Based on Medicare coverage, we suggest that you replace:
Every month
• Mask cushions and/or nasal pillows
• CPAP machine filters
Every 3 months
• Mask frame (not including the headgear)
• CPAP tubing
Every 6 months
• Mask headgear
• Chin strap (if applicable)
• Humidifier water tub

Mike,

Find it interesting that you mention the mask headgear as every 6 months and the frame every three. Both of the models I used came with the mask and headgear already assembled in a factory sealed package. Other than that, your list matches what my gov't insurance provides.

Homer

[PollCat]

I turned 65 about 5 months after I'd purchased my S9 machine. When I went to purchase new nasal pillows and headgear, Medicare wanted to know why I needed them. I politely informed them that I'd been receiving CPAP therapy since the mid-90's. However, my sleep doc still had to vouch for my need.

Now, I don't bother filing for reimbursement - it's not worth the hassle. A practice I might have to alter when I need a newer machine.

[Nyre]

Medicare may allow a new machine every 5 years but each time a new machine is issued you have to show the compliance and meet face to face with your Dr. who has to file that it is a benefit to your health. Then you have to meet with him within the 90 days compliance for Medicare to continue to pay for your new machine. Compliance is at least 4 hours each night for 70% of the time during the first 90 days of using a new machine.
Medicare and most private insurers cover scheduled replacements of all mask parts and other supplies (including CPAP machines, but we’ll talk about those in an upcoming blog post). Ask your insurance provider how often it will cover the replacement of each part. Your equipment supplier can answer any questions about this and even help you fill out and process any necessary forms. Based on Medicare coverage, we suggest that you replace:
Every month
• Mask cushions and/or nasal pillows
• CPAP machine filters
Every 3 months
• Mask frame (not including the headgear)
• CPAP tubing
Every 6 months
• Mask headgear
• Chin strap (if applicable)
• Humidifier water tub

Very informative post. Thank you