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CPAP Compliance
#1
Hi. I have been using a cpap machine for 5 months now and all is going well except for one problem that I will mention later. My first question is about cpap compliance. My girlfriend just started using a machine and was told today that Medicare just changed the compliance hours from 4 hours a night to 5 hours a night. I don't see this change on their site. Has anybody heard of this or was she told wrong?
I use nasal pillows and have no problem breathing out of just my nose. It seems however that the inside of my upper gums and inside the upper lip dry out and stick together with not the freshest feeling. Ive tried adjusting the fit and pressure of the pillows, always brush my teeth, use mouthwash, etc. Anybody else experienced this and of so what did you do about it? Thanks-
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#2
Welcome

No idea about the Medicare thing.

As for the dry mouth, you seem to have a case a FHL (Flappy Horse Lips). Grin If your tongue drops/relaxes in your mouth then the pressure gets into your mouth and pushes past your lips. This leads to what you are experiencing. About two weeks ago, out of the blue, I developed a case of FHL. The easy, if uncomfortable, cure is to use a Full Face Mask. You can also try practicing the tongue suck/seal in the daytime to try and get your body to do it at night.

You might also be opening your mouth, in which case a soft cervical collar or chin strap might help. But I would expect more general mouth dryness in that case.
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#3
If you are using a tooth paste with SLS and/or mouthwash with alcohol, could be unwittingly compounding the dry mouth issue, ask me how I know...there are several non-SLS and alcohol free options, give them a go if you haven't yet, IME this alone improved the baseline dryness significantly, the the FHL which has been short lived and sporadic for me--tongue suck seal worked without even knowing about it, I did instinctively, should be addressed as PP no doubt.
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#4
Medicare only tracks compliance to your doctors prescription.
Your doctor has to document that you are complying with the prescription and it is helping you at the end of 90 days.
Typically the DME reports compliance for the next 10 months for Medicare to continue paying. If Medicare determines your therapy has been interrupted they will stop payment.

You girlfriend needs to know what her doctor prescribed, that is what Medicare is looking at...........

My doctor prescribed 5 hours 6 days a week

The four hour, five hour, requirements as well as the 21 out 30 days requirement and the 70 % or 80% requirements all come form many other good sources but not from Medicare.

My insurance used the 4 hours for 21 days rule for only one month during the first three months. Then they paid for bill.


https://www.medicare.gov/coverage/sleep-...ories.html





(07-28-2016, 08:56 PM)Willky Wrote: My girlfriend just started using a machine and was told today that Medicare just changed the compliance hours from 4 hours a night to 5 hours a night. I don't see this change on their site. Has anybody heard of this or was she told wrong?
I use nasal pillows and have no

2004-Bon Jovi
it'll take more than a doctor to prescribe a remedy

Observations and recommendations communicated here are the perceptions of the writer and should not be misconstrued as medical advice.
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#5
Actually Orange Bear, Medicare is very specific what they consider compliance for actual use of the machine. Whether the doctor ordered more is of no interest to Medicare. Compliance is only calculated for the first 90 days.

"Adherence to CPAP is defined as usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of initial usage."

Now, did they change it from 4-5 hours? I find that unlikely. The whole point of the 4 hour compliance requirement is to show that the patient is USING the machine. That's all. The follow-up visit for the doctor within 90 days is simply to confirm that the patient is showing improvement so that the rental payments will continue. I can see no evidence of any change via the new Medicare requirements pages or frankly, on any other DME page. The OP's girlfriend should ask the DME for evidence of this requirement. Perhaps the DME mispoke or they have some other reason for telling patients that they have a 5 hour usage requirement.

As to the dry mouth, I can't help you there. I'm getting a similar problem lately ever since I turned down humidity because I was getting stuffy head. A very dry mouth, in my experience, occurs when your mouth is open, even if just a bit. I noticed that it coincided with higher leak rates (and I get VERY low leak rates with pillows).
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#6
I am looking for a reliable source that states this. The compliance information for Medicare. All I find is "they say this" from Resmed and other places but no where can I find where Medicare itself says it.

Anyone have linkage?

I ask because in all the years I have used xPAP, never has my DME asked to see the machine to confirm compliance. The original guy once joked about compliance being met judging by the condition of my headgear but he never looked at the machine itself (S7). And the same company never asked or looked at the S9 Escape.
PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.




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#7
(07-29-2016, 07:49 PM)Mosquitobait Wrote: Actually Orange Bear, Medicare is very specific what they consider compliance for actual use of the machine. Whether the doctor ordered more is of no interest to Medicare. Compliance is only calculated for the first 90 days.

"Adherence to CPAP is defined as usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of initial usage."


Bigwink

Like I said above there are many sources that quote this rule as if It comes from Medicare and many DME's and doctors also regurgitate it.

However, when I first joined the forum an heard it.......I started doing some research and discovered that it is one of those urban myths.

It may be true that many DME's and insurance agreements use this rule. It may also be part of the rules established by may other government entities world wide, that provide heath care and regulate commercial drivers licensing, but it is not a Medicare rule; despite the hundreds or web sites, sleep centers and DME's that say it is.

Willky - Yesterday 07:56 PM mentioned he went to here website and could not find the requirement. I was simply attempting to agree with his assessment that it was not on there website.

I even attached a link to the site where is tells you what the Medicare rule is.......Nevertheless, we are a nation of opinions not facts (just look at a presidential election options) People choose to believe what they want to believe. I myself am no different; it is what makes us unique as Americans

Now for those who have the patience and interest to still be reading this deep into the thread. I have attached bellow the entire Medicare Regulations Guidelines and Policy related to CPAP therapy.

Nowhere in the plethora of regulatory language below or in the associated links is there a Medicare definition of compliance even similar to the one disputed on this page

Willky's is correct it is simply not there

The code of federal regulations title 24
Title 42: Public Health
PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

Subpart F—Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

[1] §414.409 Special payment rules. [Context]

[2] §414.412 Submission of bids under a competitive bidding program. [Context]

PART 424—CONDITIONS FOR MEDICARE PAYMENT

Subpart D—To Whom Payment Is Ordinarily Made

[3] §424.57 Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges. [Context]

[4] Subpart D—To Whom Payment Is Ordinarily Made [Context]

PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

[5] Subpart F—Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) [Context]

[6] PART 424—CONDITIONS FOR MEDICARE PAYMENT [Context]

[7] PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES [Context]


TITLE 42—Public Health
CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B—MEDICARE PROGRAM

Medicare Department of Health & Human Services (DHHS) Coverage Issues Manual Centers for Medicare & Medicaid Services (CMS) Transmittal 150 Date: DECEMBER 26, 2001

Medicare National Coverage Determinations (NCD) Manual Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations REV 01/01/15 For service performed on or after 01/01/15 Previous review 10/31/13, 09/16/14

SECTION 240.4
240.4 - Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) (Effective April 4, 2005) (Effective March 13, 2008) (Rev. 96, Issued: 10-15-08, Effective: 03-13-08, Implementation: 08-04-08)
A. General
Continuous Positive Airway Pressure (CPAP) is a non-invasive technique for providing single levels of air pressure from a flow generator, via a nose mask, through the nares. The purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in obstructive sleep apnea (OSA).
The apnea hypopnea index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour. The respiratory disturbance index (RDI) is equal to the average number of respiratory disturbances per hour.
Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.
The AHI and/or RDI may be measured by polysomnography (PSG) in a facility-based sleep study laboratory, or by a Type II home sleep test (HST) monitor, a Type III HST monitor, or a Type IV HST monitor measuring at least 3 channels.
B. Nationally Covered Indications
Effective for claims with dates of service on and after March 13, 2008, the Centers for Medicare & Medicaid Services (CMS) determines that CPAP therapy when used in adult patients with OSA is considered reasonable and necessary under the following situations:
1. The use of CPAP is covered under Medicare when used in adult patients with OSA. Coverage of CPAP is initially limited to a 12-week period to identify beneficiaries diagnosed with OSA as subsequently described who benefit from CPAP. CPAP is subsequently covered only for those beneficiaries diagnosed with OSA who benefit from CPAP during this 12-week period.
2. The provider of CPAP must conduct education of the beneficiary prior to the use of the CPAP device to ensure that the beneficiary has been educated in the proper use of the device. A caregiver, for example a family member, may be compensatory, if consistently available in the beneficiary's home and willing and able to safely operate the CPAP device.
3. A positive diagnosis of OSA for the coverage of CPAP must include a clinical evaluation and a positive:
a. attended PSG performed in a sleep laboratory; or
b. unattended HST with a Type II home sleep monitoring device; or
c. unattended HST with a Type III home sleep monitoring device; or
d. unattended HST with a Type IV home sleep monitoring device that measures at least 3 channels.
4. The sleep test must have been previously ordered by the beneficiary’s treating physician and furnished under appropriate physician supervision.
5. An initial 12-week period of CPAP is covered in adult patients with OSA if either of the following criterion using the AHI or RDI are met:
a. AHI or RDI greater than or equal to 15 events per hour, or
b. AHI or RDI greater than or equal to 5 events and less than or equal to 14 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.
6. The AHI or RDI is calculated on the average number of events of per hour. If the AHI or RDI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to calculate the AHI or RDI during sleep testing must be at a minimum the number of events that would have been required in a 2-hour period.
7. Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.
8. Coverage with Evidence Development (CED): Medicare provides the following limited coverage for CPAP in adult beneficiaries who do not qualify for CPAP coverage based on criteria 1-7 above. A clinical study seeking Medicare payment for CPAP provided to a beneficiary who is an enrolled subject in that study must address one or more of the following questions:
a. In Medicare-aged subjects with clinically identified risk factors for OSA, how does the diagnostic accuracy of a clinical trial of CPAP compare with PSG and Type II, III & IV HST in identifying subjects with OSA who will respond to CPAP?
b. In Medicare-aged subjects with clinically identified risk factors for OSA who have not undergone confirmatory testing with PSG or Type II, III & IV HST, does CPAP cause clinically meaningful harm?
c. The study must meet the following additional standards:
d. The principal purpose of the research study is to test whether a particular intervention potentially improves the participants’ health outcomes.
e. The research study is well-supported by available scientific and medical information or it is intended to clarify or establish the health outcomes of interventions already in common clinical use.
f. The research study does not unjustifiably duplicate existing studies.
g. The research study design is appropriate to answer the research question being asked in the study.
h. The research study is sponsored by an organization or individual capable of executing the proposed study successfully.
i. The research study is in compliance with all applicable Federal regulations concerning the protection of human subjects found at 45 CFR Part 46. If a study is Food and Drug Administration-regulated, it also must be in compliance with 21 CFR Parts 50 and 56.
j. All aspects of the research study are conducted according to the appropriate standards of scientific integrity.
k. The research study has a written protocol that clearly addresses, or incorporates by reference, the Medicare standards.
l. The clinical research study is not designed to exclusively test toxicity or disease pathophysiology in healthy individuals. Trials of all medical technologies measuring therapeutic outcomes as one of the objectives meet this standard only if the disease or condition being studied is life-threatening as defined in 21 CFR §312.81(a) and the patient has no other viable treatment options.
m. The clinical research study is registered on the ClinicalTrials.gov Web site by the principal sponsor/investigator prior to the enrollment of the first study subject.
n. The research study protocol specifies the method and timing of public release of all pre-specified outcomes to be measured, including release of outcomes if outcomes are negative or study is terminated early. The results must be made public within 24 months of the end of data collection. If a report is planned for publication in a peer-reviewed journal, then that initial release may be an abstract that meets the requirements of the International Committee of Medical Journal Editors. However, a full report of the outcomes must be made public no later than 3 years after the end of data collection.
o. The research study protocol must explicitly discuss subpopulations affected by the treatment under investigation, particularly traditionally underrepresented groups in clinical studies, how the inclusion and exclusion criteria affect enrollment of these populations, and a plan for the retention and reporting of said populations in the trial. If the inclusion and exclusion criteria are expected to have a negative effect on the recruitment or retention of underrepresented populations, the protocol must discuss why these criteria are necessary.
p. The research study protocol explicitly discusses how the results are or are not expected to be generalizable to the Medicare population to infer whether
Medicare patients may benefit from the intervention. Separate discussions in the protocol may be necessary for populations eligible for Medicare due to age, disability, or Medicaid eligibility.
C. Nationally Non-covered Indications
Effective for claims with dates of services on and after March 13, 2008, other diagnostic tests for the diagnosis of OSA, other than those noted above for prescribing CPAP, are not sufficient for the coverage of CPAP.


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#8
Careful with the double posts. When I first got the machine, the wireless modem sent usage data to the DME (I think). Anyway, it sent it somewhere, but not to the doctor. I have to take him the chip every time we review my therapy. I always wondered how Medicare found out about the data and what compliance standards they applied.
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#9
(07-29-2016, 10:39 PM)Jim Bronson Wrote: Careful with the double posts.

Probably a software hiccup. Some server maintenance is ongoing tonight, which could be the cause.

I deleted 0rangebear's duplicate post.

Coffee
SuperSleeper
Apnea Board Administrator
www.ApneaBoard.com


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.



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#10
Of course, I've never done it myself. Smile
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