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Justifying new Cpap machine
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RockABye Offline

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Posts: 31
Joined: Sep 2013

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: TapPap; Respironics Nuance
Humidifier: H5i
CPAP Pressure: 5-15
CPAP Software: SleepyHead

Other Comments: Moderate OSA;

Sex: Female
Location: OK, US

Post: #11
RE: Justifying new Cpap machine
(11-24-2013 06:43 PM)sleepy_one Wrote:  I am now worried about the heated hose the equipment company sold me. Will medicare pay for a heated hose a month after they paid for a non-heated one? They said "it's a different code" but what does that mean?
Oh-jeez

And now I'm feeling that the doctor is costing us money too, as she ordered the expensive at home study instead of a new machine, which is what I think my husband will eventually end up with. (She is a sleep specialist and seems really good except for this new machine issue.) So then we will end up paying for the home study and machine rental AND a new machine.

Sleepy_One, it's not necessarily a bad thing for the doctor to order a new sleep study if your husband's last one was 5 years ago when he got his machine. She needs to determine if the pressure setting from his previous study is correct for him or needs to be adjusted. Many things can affect the setting over the years such as losing weight, gaining weight, general health conditions, etc. Some insurance companies (including Medicare) require a sleep study before they will pay for a new CPAP machine. My sister's insurer required a home study to determine if a study was needed in a sleep lab and when the study showed that she did have enough events to be diagnosed OSA, then she had to have the sleep lab study done before they would pay for the CPAP! There's so many rules and regulations now that it's hard to know what's required.

As for Medicare paying for the heated hose, when my friend got her machine, the DME didn't provide the heated hose either and she had problems with "rainout" (water condensation in the tube). She asked her doctor to write a prescription for the heated hose within just a few days of getting the CPAP machine. Medicare paid for the heated hose since it's a separate billing number (not considered part of the original machine but like an accessory), and was a "medical necessity". Your situation sounds similar, so I doubt you'll have any problem with them paying for your heated hose. If they do, just ask your doctor to write the prescription for it and have the DME submit that.

Good luck and try not to worry. All these things will work themselves out. Bigwink
11-24-2013 11:35 PM
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archangle Offline
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Posts: 3,159
Joined: Feb 2012

Machine: ResMed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: ResMed Swift FX
Humidifier: ResMed S9 H5i
CPAP Pressure: 16-20
CPAP Software: ResScan SleepyHead EncoreBasic

Other Comments: Happy PAPper

Sex: Undisclosed
Location: USA

Post: #12
RE: Justifying new Cpap machine
(11-24-2013 05:56 PM)cbramsey Wrote:  Medicare guidelines allow for a new XPAP machine every 5 years unless your circumstances dictate a new machine sooner.

Good luck to you. Sleep-well

There have been reports that this is no longer true with medicare. They will only replace if there is something wrong with the old machine or there is a prescription change such as auto, bilevel, ASV.

There have also been reports some DMEs will tell patients that there is still a 5 year rule and they simply report to Medicare/insurance that the old unit is broken.


There's some info here:
http://www.resmed.com/us/documents/10149...eet-us.pdf

Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
11-25-2013 12:52 AM
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me50 Offline

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Posts: 2,559
Joined: Aug 2013

Machine: resmed S9 VPAP Auto
Mask Type: Nasal mask
Mask Make & Model: Wisp and Silicone Head gear
Humidifier: resmed H5i
CPAP Pressure: 18/8
CPAP Software: SleepyHead

Other Comments:

Sex: Undisclosed
Location: USA

Post: #13
RE: Justifying new Cpap machine
I reported it to my insurance company (3 times and they did not send it to the investigation department so I reported it to a supervisor and it is being investigated now) and to the DME.

We shall see. If I had been responsible for a co-pay, I definitely would not have paid that co-pay.
11-25-2013 07:49 AM
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sleepy_one Offline

Members

Posts: 16
Joined: Nov 2013

Machine: PRS1 Auto 60 Series
Mask Type: Nasal pillows
Mask Make & Model: Pilairo Q
Humidifier: PRS1 Auto 60 Series w/ Heated Hose
CPAP Pressure: 10-16
CPAP Software: Not using software

Other Comments: 10 year "brick" CPAP user. Brand new APAP user.

Sex: Undisclosed
Location:

Post: #14
RE: Justifying new Cpap machine
(11-24-2013 11:35 PM)RockABye Wrote:  Sleepy_One, it's not necessarily a bad thing for the doctor to order a new sleep study if your husband's last one was 5 years ago when he got his machine. She needs to determine if the pressure setting from his previous study is correct for him or needs to be adjusted. Many things can affect the setting over the years such as losing weight, gaining weight, general health conditions, etc. Some insurance companies (including Medicare) require a sleep study before they will pay for a new CPAP machine. My sister's insurer required a home study to determine if a study was needed in a sleep lab and when the study showed that she did have enough events to be diagnosed OSA, then she had to have the sleep lab study done before they would pay for the CPAP! There's so many rules and regulations now that it's hard to know what's required.

Yes, it has been 5 years since his last sleep study. Wouldn't the doctor have been able to get the same info off an owned machine (if she had ordered him a new one) as she can get off the one month rental machine?

My last study was 10 years ago and I got the new fully data capable machine (the exact same model as my husband has for a one month rental) and NO home sleep study ordered, so I am confused.

Anyway, I really can't thank everyone enough for their replies. This forum has been incredibly helpful!

Thanks
11-25-2013 02:22 PM
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