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Help!!! Medicare Nightmare
#1
Hopefully someone with experience can help.
In 2007 I was diagnosed with sleep apnea and prescribed CPAP. I was ultimately non-compliant at the time and discontinued it.

In 2012 I realized this was still an issue I had to deal with so I had another sleep study. Part of the study was done without CPAP and part with CPAP, however CPAP alone did not resolve the issues so a follow-up study with BIPAP was recommended.

For a variety of reasons I did not get around to the study on BIPAP until this past February (2015). The study was not split but was done only on CPAP and BIPAP.
I received an order for and was started on BIPAP in June and have been generally happy with it and compliant.
My homecare company contacted me today and said Medicare requires me to do another sleep study because I was non-compliant in 2007.
This makes no sense. I hope someone can help out by sharing some insight and their experiences.
Thanks for taking time to read this and thanks in advance for any replies I may receive.
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#2
(08-19-2015, 12:44 PM)Anthony P Wrote: Hopefully someone with experience can help.
In 2007 I was diagnosed with sleep apnea and prescribed CPAP. I was ultimately non-compliant at the time and discontinued it.

In 2012 I realized this was still an issue I had to deal with so I had another sleep study. Part of the study was done without CPAP and part with CPAP, however CPAP alone did not resolve the issues so a follow-up study with BIPAP was recommended.

For a variety of reasons I did not get around to the study on BIPAP until this past February (2015). The study was not split but was done only on CPAP and BIPAP.
I received an order for and was started on BIPAP in June and have been generally happy with it and compliant.
My homecare company contacted me today and said Medicare requires me to do another sleep study because I was non-compliant in 2007.
This makes no sense. I hope someone can help out by sharing some insight and their experiences.
Thanks for taking time to read this and thanks in advance for any replies I may receive.

The stated reason makes no sense. What you did 8 years ago is old news. Medicare often makes no sense. They will suddenly deny a person a number of test strips that they have approved for years; while they will waste money on an unneeded study.

Fighting Medicare is like tilting at windmills. OTOH, perhaps the homecare company is either wrong or lying. For me, that would be the point of attack. If it were me, I'd ask to see a letter from Medicare that states it is required or the black and white letter of Medicare rules that says it must be done.

Or, an even simpler question for them: What happens if I don't do the study?

Edit: In rereading your history, it reads like you have two gaps in therapy: 2007-2012 and 2012 to 2015.
Likely everything done in 2007 ans 2012 is not being considered.
In February they did a titration on Bilevel. I believe Medicare is asking that a sleep study to prove apnea have been done first.
So, they will accept the titration as the first study (with a little creative writing by the home care) and call the next study the titration.
I'll hazard a guess that you have to do it for them to get paid.

Medicare rules keep changing to rein in costs -- they spend more in the end; but some bureaucrat has a job.
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#3
Contact each of the providers where you had previous sleep studies done and get your records. This might be sufficient. I agree that calling Medicare and asking exactly what is needed is the first order of business. Medicare needs to establish that your PAP therapy is medically necessary. That might be met by producing old records, or even a current recommendation from your doctor. You won't know until you ask directly...don't let the DME be your go-between on this.
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#4
Get with your medicare insurance co directly.
This is likly a DME policy to be sure they get paid and let doc charge a new study, not a medicare denial.
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#5
What year did you start Medicare? And did the supplier confirm they have a copy of your 2012 split night study? If yes, was there a problem with it? E.g. No face-to-face doctor's notes within 6 months prior to the study.
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#6
The rules say, you should have tried CPAP and failed in order to qualify for BIPAP

Also titration protocol recommend BIPAP, whenever pressure 15 or higher is reached during CPAP titration
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#7
Hi Anthony P,
WELCOME! to the forum.!
Hang in there for more answers to your questions and good luck to you with getting your insurance problems straightened out.
trish6hundred
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#8
My experience with Medicare, although with circumstances different from yours, has not been a cake walk either. One suggestion based on my experience is to avoid an in-home sleep study if at all possible.
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#9
https://www.cms.gov/site-search/search-r...p%20claims
For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/dire...onal/SHIP/
or here http://www.medicareinteractive.org/
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#10
Personally i havent had problems with medicare but twice. Both times it wasnt medicare at all but the DME demanding stuff and claiming it was Medicare demanding it
Quick call to my Medicare insurance ended quickly with a threeway call initiated by Medicare , with me , DME and Medicare during which Medicare Rep told the DME to "knock it off and stop making false demands".
Also, Medicare will pay for whatever machine your doc prescribes after the sleep study.
I also began with a home study.
I still bey its your DME playing cya



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