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How to qualify for medicare- what I have learned
#11
RE: How to qualify for medicare- what I have learned
It is hard to know what the "rules" were in 2016, but it is somewhat obvious that some steps were not followed. There could be more than one mistake.

To start, you need to go to medicare.gov to find the guidelines, your coverage and providers. Medicare pays 80% and you pay 20%. If you have a supplement then that will kick in pending deductibles. If you are on an advantage plan, you need to follow your plan.

Here are the things that your pulmonologist probably didn't do, or maybe didn't know about. He needed to document in his notes your sleep apnea symptoms and the necessity to get a sleep study. This is an important piece since Medicare will need this if your study results are less than 15 AHI, or you need to justify a more advanced machine. This is the job of your doctor.

You will need to go to a DME that is a Medicare provider; check Medicare.gov.

You will also need a follow-up visit with your doctor after 30 days, (my doctor said 60 days) and before 90 days.

You need to meet compliance levels of a minimum of 4 hours per day for 21 days per 30 day period.

John
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#12
RE: How to qualify for medicare- what I have learned
I could never get a straight  answer as to why my machine was repossessed in 2016 but article below from 2016 shows this was a common issue back in 2016.  However, interestingly when I went to see my pulmonolgist a few weeks back, who I had not seen in over 3 years (I decided to followup with him since I have been using the loaner he gave me back in 2016), he did not even suggest doing a home sleep study. Just told me to  keep doing what am doing. !? Now from reading what I am being advised on this board and the sleep doctor I socially met while traveling last week in a  different state, I am disappointed my pulmonolgist  did not even suggest trying for a home sleep study By the way, as I mentioned in my first post, the sleep doctor I met was suggesting that I find a test where it is not mail order, but a local test where the test equipment would be delivered and picked up and who had licensed physicians who could interpret the test results and (I believe) write the script for the CPAP machine, etc.  Not sure why he was trying to  attempt  this route but he was having trouble finding one that does it this way in either FL or NY when he put in my zipcodes (and I do not remember what websites he went to).  Like I said I met him at his house in a social setting and I had never met him before( I knew his wife from college but never met him before)  and in the brief time I was at his house he was trying to guide me in this route but in his limited time on the computer, he could not find a test company who delivers and picks up.  He must have had a reason for wanting to go this route although in our limited time together I really did not get the answer.

re: article I mentioned above  I cannot  Sad  post the article  referenced above about the crazy rules from 2016/2017 which is from the huffpost since I am a new member
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#13
RE: How to qualify for medicare- what I have learned
(02-14-2020, 12:24 PM)eajeff Wrote: I could never get a straight  answer as to why my machine was repossessed in 2016 but article below from 2016 shows this was a common issue back in 2016.  However, interestingly when I went to see my pulmonolgist a few weeks back, who I had not seen in over 3 years (I decided to followup with him since I have been using the loaner he gave me back in 2016), he did not even suggest doing a home sleep study. Just told me to  keep doing what am doing. !? Now from reading what I am being advised on this board and the sleep doctor I socially met while traveling last week in a  different state, I am disappointed my pulmonolgist  did not even suggest trying for a home sleep study By the way, as I mentioned in my first post, the sleep doctor I met was suggesting that I find a test where it is not mail order, but a local test where the test equipment would be delivered and picked up and who had licensed physicians who could interpret the test results and (I believe) write the script for the CPAP machine, etc.  Not sure why he was trying to  attempt  this route but he was having trouble finding one that does it this way in either FL or NY when he put in my zipcodes (and I do not remember what websites he went to).  Like I said I met him at his house in a social setting and I had never met him before( I knew his wife from college but never met him before)  and in the brief time I was at his house he was trying to guide me in this route but in his limited time on the computer, he could not find a test company who delivers and picks up.  He must have had a reason for wanting to go this route although in our limited time together I really did not get the answer.

re: article I mentioned above  I cannot  Sad   post the article  referenced above about the crazy rules from 2016/2017 which is from the huffpost since I am a new member

Do you have a primary care physician that you see on a regular basis?  If so, just go see them and ask for a home sleep study.    It’s really easy.  They have done this before with other patient’s.
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#14
RE: How to qualify for medicare- what I have learned
I found the 2016 Huffington Post article.  I don't know if there have been any changes since it was published, but I would be very disappointed if I had been on CPAP since 2006 and my doctor did not document my sleep apnea symptoms such as daytime sleepiness, impaired cognition, insomnia, etc. as a reason for a sleep study and I failed to reach the Medicare guidelines for OSA and was denied.

Granted, Medicare can be a pain, and I'm not saying Medicare won't mistakenly deny coverage, but the person's doctor in the article, and your pulmonologist needed to document a case as the reason for a sleep study.

This is what Medicare requires, (it was already posted), but I decided to include it again:

A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:
    AHI or RDI greater than or equal to 15 events per hour, or
    AHI or RDI greater than or equal to 5 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.

If you fall into the second category, you need your primary physician, pulmonologist, or your sleep doctor to be willing to provide documented symptoms.  If they are not willing to provide that to Medicare, you will be denied.  It would be best to have the symptoms documented prior to the sleep test.  I was required to provide documentation prior to my ASV titration existed before I could get a machine. I’ve been on CPAP since 2001.

This may seem to a waste and too much of an inconvenience, but it is reality if you want to use Medicare.  For most of my CPAP life, I was off the grid when it came to my CPAP stuff.  I'd buy a machine from a private party, supplies off eBay, and occasionally re-surface and get a prescription so I could stock up on a masks.  The cost of an ASV drove me to the surface and now I let MyAir track me and a DME send me supplies through Medicare.

John
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#15
RE: How to qualify for medicare- what I have learned
So now that I am home (I was traveling before when I wrote prior messages)  I went back to my overnight sleep study results done in 2016(see attached)--the one where my pulmonologist had started me on cpap (supposed to covered under medicare), --nly to find that after 6 weeks the machine was repossessed because medicare did not cover it after all.  And pulmonolgist gave me a refurb machine I have used for almost 4 years  Attached is page from sleep study.  Is it your opinion that at that time, I had such "mild" sleep apnea that it is no surprise medicare ultimately turned me down?.  Wonder if it is even worthwhile for me to pursue a home sleep study now?


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