370
edits
Changes
→DME Says I Need a New Sleep Test
##* Full Face mask(s) tried (note model(s) and results)
== DME or Sleep Specialist Says I Need a New Sleep Test =='''A DME ''' has no authorization to diagnose, prescribe or otherwise perform any medical function such as referral to sleep tests. The role of the DME is limited to filling a doctor's prescription and coordinating any insurance or Medicare approval, denial and reimbursement activity. Many DME providers also have Respiratory Therapists on staff that setup devices in accordance with prescribed pressure, assist patients with fitting masks, solving therapy problems and tracking usage compliance. The DME is not authorized to change machine settings without a doctor's order, and cannot refer a patient to a sleep test. They can inform a patient or their doctor that information needed to file a claim may be missing or insufficient. It is common for a DME representative to tell a patient they need a new sleep test, however if a valid sleep test has been performed at anytime in the past that meets the requirements of the insurer, and a treating physician has continued to issue a prescription for devices and equipment based on that history, it is not the role of the DME to do anything but submit a claim containing that information to the insurer. '''Sleep Specialists or Doctors''' serve singular function specified by Medicare/CMS requirement; to sign off on a sleep study ordered by a '''treating physician''', and used to document a diagnosis of obstructive sleep apnea. There is no requirement that a treating physician be a board certified sleep specialist. Many sleep specialists attempt to convert the subjects of sleep tests to routine care and recurring appointments. The economic incentive for a specialist to have an ongoing physician-patient relationship is obvious; however there is no requirement to see a specialist once the test is complete. The treating physician can be the same doctor a patient sees for annual exams and routine health care. It is advisable that the patient request their treating physician to assume responsibility for their ongoing PAP care and prescriptions. This will generally require routine discussion of your CPAP therapy and informing your DME of the name, address and fax for your treating physician. This arrangement saves the cost of routine vists to a sleep specialist and removes the economic incentives to perform recurring, unnecessary clinical sleep tests.
There is no mandate for re-testing when a replacement machine is acquired and the patient has been under the care of a physician, regularly discussed their CPAP therapy and indicated it is beneficial. The choice of a device to treat apnea is between the doctor and his patient and can be supported by a titration if the doctor deems it necessary, however; titration exams are never a requirement to obtain a PAP device. Medicare rules are typical. A patient qualifies for CPAP after an in-person clinical evaluation and a positive sleep test using PSG or type II, III or IV home sleep test. While the criteria for a positive sleep test is defined as greater than or equal to 15 events per hour, or 5 or more events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. [https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=226 CMS Medicare Requirements for CPAP]
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