Have compliance criteria for Medicare reimbursement changed?

[fredkahan]

I enrolled in CPAP therapy as a Medicare patient on September 21 and am plugging away at achieving compliance.
I have received an information note from my DME (LinCare) in which they cite compliance criteria for insurance coverage as "Use therapy for 4 hours each night for 30 consecutive days between days 31 & day 90 (of receipt of CPAP machine)"

This is more stringent than the criterion quoted elsewhere, e.g. ResMed, "Objective evidence of adherence to use (defined as use of PAP devices for 4 or more hours per night on 70% of nights during a consecutive 30-day period anytime during the first 3 months of initial use) of the PAP device,.." 
 
I sure hope that the more relaxed criterion prevails!

[GuyScharf]

I am not aware of any changes in Medicare compliance requirements, which are as you quoted from ResMed.

[SarcasticDave94]

Since my primary is Medicare starting this past May, and my new pulmonary doc just ordered a new ASV (long story and not pertinent), I am about to find out the Medicare way on compliance. I'm not waiting for it to slap me in the face though. I'll be digging in on details about this Monday. I will report the findings. If others dig up the info, please update us.

[SideSleeper]

I just got a new ResMed after 5 years on a PR machine. No compliance whatsoever except from my sleep doc--3 months. That is his request, not Medicare I think. He's a great guy and I go willingly. I originally had the 4 hr per night, 70% in 30days. It is possible to actually talk to someone at Medicare--just be prepared to be on hold for awhile.

[SarcasticDave94]

Copied on my side, thanks.

[OpalRose]

I have a Medicare Advantage plan and received this information:  

Compliance:
Medicare requires that a patient use CPAP for more than 4 hours per night on 70% of nights (21 nights) during a 30-day consecutive period any time in the first three months of use.

Patient must also have a face to face appointment with their doctor any time after the first 30 days, but before the 90 days expires.

I have no information that this has changed, but doesn't mean it hasn't.

Note: If your skip the second part about having a face to face with your doctor, they can deny coverage.

And I wouldn't count on Lincare or any other DME to give you accurate information. I had to take it as far as to have a three way phone call between myself, Lincare and Humana, where my Humana Medicare representative took great pains to get it right with Lincare.

[Elgeeone]

I have had 5 machines through Medicare since dx. This last replacement was hard. My doctor was in another state. I went to see him, he ordered the vauto and told me I had to come back this time for a face to face after 30 days but before 90. Unfortunately Covid hit and I couldn’t go back to him. My family doc took over my rx’s and put a f2f note in our virtual visit notes. I have had zero issues with Medicare. First time a replacement needed that f2f so some things have changed a little. I was able to finally have a televisit with the other doctor. Another post. Good luck. And record any conversations with the Medicare csrs. They will tell you outright that their information could be wrong and they won’t pay.

[SideSleeper]

Elgee1, your comment about seeing the doctor by 3 months make sense--apparently Medicare does require that even on a replacement machine, thus my 90 day appointment.

[fredkahan]

Thanks, to all of you, for your advice. I'll tell you how it all works out after the 0 day period .. I do have a tele-face-to-face scheduled with the prescriber.

[Elgeeone]

I hope it goes well. I ended up with Aerocare after my Mom n pop dme got bought out by Verus. Very few medicare dmes after their failed bidding program, ehich I think is on hold. Aerocare is not perfect by any means, but way better than the service from Verus and Lincare and Apria.