Tring to get a new machine

[jeryray]

About 6 weeks ago my system 1 bipap had a power problem inside. This machine came from Cigna through Apria Health. I have been using a Bipap for 10 years.

I am on Medicare now. My doctor wrote a prescription for a new machine and medicare had me do another sleep study (no mask or machine). After the study my throat was sore for 2 days, felt like strep. Guess I was choking on my tongue. Now Medicare wants another sleep study so they go cheap and give a cpap.

After 7 weeks with no machine I purchased my own Respironics DreamStation BiPAP Auto with Heated Humidifier. This set to auto and my avg ahi is 1.9. So it does work for me.

I don't know if I should do another study if they are going to force a cpap instead of a bipap.

PS I will have to pay for my own supplies since I bought my own machine.

Any suggestions?

TIA

[justMongo]

You have a new BiPAP and it works for you. Why have another study?
First study was to prove to medicare that you have apnea.
Second study is generally a titration on a machine.

I got my second machine out of pocket; and I still get medicare to pay for my supplies.
I just informed the DME what my new machine was. It doesn't follow you have to pay for your own supplies just because you bought the machine.

Regards,

Mongo

[jeryray]

You have a new BiPAP and it works for you. Why have another study?
First study was to prove to medicare that you have apnea.
Second study is generally a titration on a machine.

I got my second machine out of pocket; and I still get medicare to pay for my supplies.
I just informed the DME what my new machine was. It doesn't follow you have to pay for your own supplies just because you bought the machine.

Regards,

Mongo

So would you do the additional study and try to get them to provide a machine?

Thanks

[bwexler]

Why fight the system if you already have a machine?
You might want to take a Sleepyhead printout to your doc and get a prescription from him specifying the machine and settings you have and try to get reimbursed from Medicare, but they normally rent for a year requiring a monthly copayment.

[justMongo]

You might want to take a Sleepyhead printout ...

I don't believe SleepyHead works with the PR DreamStation.

So would you do the additional study and try to get them to provide a machine?

Not at this point -- you have a new machine; and it's doing the job.
Why have a second study? (Which would be a titration study.)

[jeryray]

I have the Encore2 installed and working. May please the Doctor, but no Medicare.

[vsheline]

About 6 weeks ago my system 1 bipap had a power problem inside. This machine came from Cigna through Apria Health. I have been using a Bipap for 10 years.

I am on Medicare now. My doctor wrote a prescription for a new machine and medicare had me do another sleep study (no mask or machine). After the study my throat was sore for 2 days, felt like strep. Guess I was choking on my tongue. Now Medicare wants another sleep study so they go cheap and give a cpap.

After 7 weeks with no machine I purchased my own Respironics DreamStation BiPAP Auto with Heated Humidifier. This set to auto and my avg ahi is 1.9. So it does work for me.

I don't know if I should do another study if they are going to force a cpap instead of a bipap.

PS I will have to pay for my own supplies since I bought my own machine.

Any suggestions?

TIA

Hi jeryray,

I suggest you should have the titration. I assume you have already asked for your doctor to appeal for the titration to be changed to a bilevel titration, without success. No matter.

If you are given an APAP or a fixed-pressure CPAP machine as result of the titration, try it out. You could try it for at least an hour or so each night for a week. If you find you cannot tolerate it, just return it to the DME and let them and your doctor know you were unable to tolerate it. And ask the doctor to apply for preauthorization for a bilevel titration. I'm pretty sure it will be granted.

Or, if you find you can tolerate it but are still having the same issues which caused you to need the bilevel machine earlier, then work with the doctor to have the machine upgraded to a bilevel.

Maybe U.S. Medicare needs to hold the lid on expenses by seeing if patients can achieve compliance and an RDI less than 5 while using a standard CPAP or APAP machine. (Medicare pays the DME the same amount for a fixed-pressure CPAP as for an APAP machine, and I think it is up to the patient to request the doctor to write the prescription for the APAP machine they want. I think patents would have most chance of success with an APAP.)

But when patients are unable to be compliant because of the exhale pressure or whatever, or unable to achieve an adequate RDI, Medicare will want to provide a bilevel if needed.

In addition to getting another bilevel machine if needed, this will likely save you a ton of money over the long haul, as otherwise large out-of-pocket costs for masks and supplies would add up over time.

[robertbuckley]

I do not understand the denial from Medicare or requirement for a new sleep study. I am also in the NY area and recently under Medicare and have to use Apria (or another successful "bidder") and was using Bi-PAP when I turned 65. The guidelines from Medicare state:
(quote)
"Beneficiary Entering Medicare
If the patient had a PAP device that was originally covered by another insurance company and now requires a new device or
supplies under Medicare, the following are required prior to billing:
1. Qualifying sleep study that occurred prior to the Medicare effective date.
2. Face-to-face patient evaluation with the treating physician after the Medicare effective date that indicates the patient’s
diagnosis of OSA and the patient continues to use the PAP device.
3. A new prescription.
There is no trial period for patients qualified under the Beneficiary Entering Medicare or Replacement PAP requirements.
However, if the patient had a CPAP unit previously and switches to a bi-level or vice versa, the patient must qualify for the new
device following the new set-up guidelines." (end quote)

It seems to me that somewhere along the line someone didn't dot the i's and cross the t's in the paperwork and indicate that it was 1) a replacement machine, and 2) go through the above recitation. While the span of years for a new machine is supposed to be 5 (and yours is 10, so you qualify), Medicare has no knowledge of when you got a machine the first time around outside of Medicare and I have been told doesn't check. Regardless, you are over the 5 years.
Do not know what you do to get this reversed - appeal it I guess - to receive some reimbursement of your purchase. The supplies should not be any problem. Call Apria and ask to speak to a rep that deals with Medicare newbies (they have specialists in this) and they will be happy to help get the paperwork from the Dr. that you need. Good Luck !