Your med. necessity form may be in limbo

[PaulaO2]

I poked around using Google and can't find anything from CMS (Medicare) after 2008 other than clarification of verbage. Even what little I found dealt more with the sleep test than with the machines. I did find some information by DMEs about the guidelines, but most of them are from 2010.

The only compliance information I found was comments made by users, not by Medicare. (I've never, ever had to show compliance data)

[Dawei]

Right now, I'd agree with your overall surmise, Super, assuming that my sleep center was incorrect in describing new signature guidelines from Medicare as of Nov. 2008.
About your number three statement, from what the DME told me, Medicare requires them to file paperwork codes with Medicare, one of which indicates that a medical necessity form has been signed and is on file. I was given the impression that this is not new and has been required for some time. The DME does not have to send the med. necessity form to Medicare but does still have to indicate to them that this document is on file.
Perhaps someone can obtain a verification of this from another DME to show it's required for all of them. It sounds to me like this is an "internal" requirement between Medicare and DMEs and as such may not be published for us to find.

[SuperSleeper]

Thanks Paula & Dawei...

That was my big question - (on a cert of medical necessity). If Medicare requires that or not... and if so, can one be written by any old doctor or does it have to be a sleep doctor?

If anyone has authoritative info on this, please share with us!

[zonk]

Medicare coverage
http://www.cms.gov/medicare-coverage-dat...earch.aspx

Certificate of medical necessity
http://www.cms.gov/Medicare/CMS-Forms/CM...s10269.pdf

[PaulaO2]

I have to have a form of medical necessity before they will pay for my wheelchair. (but then you're talking about an 18-20K $ device) When I got my current machine last year or so, all I needed was a prescription from the doc. I got one from my GP. The DME never asked for anything else.

[SuperSleeper]

Medicare coverage
http://www.cms.gov/medicare-coverage-dat...earch.aspx

Certificate of medical necessity
http://www.cms.gov/Medicare/CMS-Forms/CM...s10269.pdf

Good info, Zonk. Thanks!

[zonk]

I can also stay on topic

[Dawei]

Yes you can, Zonk. Impressive research. It certainly looks like Medicare requires the cert. since they created it. Yet, I still wonder about my DME telling me they keep the cert. on file and just confirm to Medicare that they have one completed for the pt. What sounds more reasonable would be that they send the cert. to Medicare and keep a photocopy. As for any old doc filling out a cert., we can see there's nothing indicating otherwise on the form. Along this line, when on the phone with the woman at the hospital's sleep center, I asked about the docs who staff the center because I had the impression they all are members of a fairly large pulmonology group in town. She said that several from that group do staff the sleep center, but only four of them are certified sleep docs. That seems to confirm the idea that any doc can sign the cert., doesn't it.
Paula, it seems that all we patients usually know or are told about is the need for a script from the doc to get our equipment from a supplier. That's been my experience. I carried the script for my Autoset from the sleep center to the DME, and the DME filled it. Now we know that along with the script they also need the cert. of med. necessity which usually happens "automatically" without our necessarily knowing about it. I became aware of it only because the cert. never got done when I got my new machine and masks, and as a result I wasn't getting monthly bills to start paying for it when I began calling to ask why.

[SuperSleeper]

Eventhough there is an actual Medicare form for Medical Necessity, I'm still not completely certain that such a form must be filled out in order to get Medicare to pay for CPAP.

There's tons of government forms out there, but not all of them are required.

There's the rub.

[PaulaO2]

My GP did ask me later if I had ever gotten the machine. I said yes and she re-confirmed that she didn't mind writing the 'script at all. She never mentioned having to do more.

I think, based on my many years of experience with the lunacy of Medicare, is that it probably is required but each regional office that approves/disapproves purchases may or may not request one. Each regional office is different. Some are more relaxed. Some are very by-the-book.

For example, if this were the first CPAP machine for a patient, they probably would require it. But since it was my second, they did not.