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Medicare 5 years new BiPAP..
#1
Medicare 5 years new BiPAP..
I just got off the phone with my provider and was told that if my machine was 5 years old it still had to be broken to get a new machine. I have a dreamstation and wanted upgrade. Is that true it must be “broken”?
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#2
RE: Medicare 5 years new BiPAP..
ResMed provides the Medicare guidelines (below); I can't find them on the Medicare site, however. A machine 5 years old or older does not have to be "broken," though it does have to have sustained "irreparable wear" or "deterioration." I hope another forum member will be able to say more about how Medicare understands that.

More than five years
The replacement of an item past the five-year lifetime will
be considered in cases of irreparable wear if the item has
been in continuous use by the patient, on either a rental
or purchase basis, for the equipment’s useful lifetime.
• Irreparable wear:
– Irreparable wear refers to deterioration sustained
from day-to-day usage over time and a specific
event cannot be identified.
– In cases involving irreparable wear, the Reasonable
Useful Lifetime (RUL) of the equipment is taken into
consideration, and in no case can it be less than
five years old.
– Computation of the useful lifetime is based on when
the equipment is delivered to the patient, not the
age of the equipment.
– A physician’s written order is needed to reaffirm
the medical necessity of the item.
• If a PAP machine is replaced following the five-year RUL,
there must be a face-to-face evaluation by the treating
physician documenting that the patient continues to
use and benefit from the PAP machine. There is no
requirement for a new sleep test or trial period. Note:
If a DME item reaches its five-year life expectancy, is
in good working order and meets the patient’s medical
needs, it should not automatically be replaced.
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#3
RE: Medicare 5 years new BiPAP..
I don't know yet Medicare paths and intricate methods of madness as I had on my prior healthcare. In part I have not been on Medicare short of 2 months. An aspect to consider regardless of the 5 year old marker, if medical necessity changes and is proven in your medical charts, then machine changes ought to be rather straightforward from there. I am guessing, but being 5 years old along with that wear and tear of age and use may be considered irreparable damage. But what do I know? I'm just some kid sitting in Mom's basement and posting on a web forum.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Medicare 5 years new BiPAP..
You must verify that your DME supplier is a Medicare Participating Provider that accepts assignment. Many providers claim to "accept Medicare", but if they are not a "Participating Provider", they may charge fees and costs in addition to your coverage. Check here for participating providers in your area, or to verify your DME is a participating provider https://www.medicare.gov/supplierdirectory/search.html

The reasonable usable life (RUL) of a CPAP is 5 years. While the person you spoke with is "technically" correct, many providers will deem a machine that is over 5 years to be unrepairable because it has exceeded its service life, or they just check the box for broken. The alternative is to accept that you will be without a machine for several months after yours fails, and you wait on the approval process to complete. You can escalate your concern about impending machine failure to a manager at your DME or find a more cooperative supplier. We see this done all the time.
Sleeprider
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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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#5
RE: Medicare 5 years new BiPAP..
Thank you for the information.  It looks like it might be a fight to get one but I am going to try.  I need to make an appointment with the sleep dr. asap.
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#6
RE: Medicare 5 years new BiPAP..
A sleep doctor specialist is not needed, or in my opinion wanted. My primary physician handles all my sleep therapy needs. We make sure my medical records include compliance data and that I benefit from my BiPAP therapy. We do this every year. There are specific checkboxes that a DME needs to verify to get approval, and I make sure those are documented. Sometimes it's just a question from the doctor that therapy is going well and I'm using my equipment. The DME also verifies I am using the machine and need supplies. I sometimes take in some OSCAR charts and my doctor puts those in the record. So far, that has worked well. The problem with sleep specialists is they don't really make any money without testing you. We don't need a test, we need continuing care and prescriptions. I have not seen a specialist since 2008. The big issue is to be sure that you have at least one diagnostic study in your medical records. After that, you just maintain a record of use and therapy benefit.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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