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Medicare Coverage
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apnea earlybird Offline

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Posts: 1
Joined: Dec 2012

Machine: remstar pro series m
Mask Type: Nasal mask
Mask Make & Model: unsure
Humidifier: unsure
CPAP Pressure: 17
CPAP Software: EncorePro

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Sex: Female
Location:

Post: #1
Medicare Coverage
I have had sleep apnea for 26 years. I cannot fall asleep without the cpap being at proper pressure. Therefore, when I had my most recent sleep study I showed no apnea episodes. According to the most recent Medicare rules this means I do not have apnea and they will not pay for a new machine or any supplies. What do I do now? Any suggestions? Has anyone else run afoul of the new Medicare rules?
12-22-2012 12:18 PM
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PaulaO2 Offline
Wiki Editor
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Posts: 8,064
Joined: Feb 2012

Machine: S9 Autoset
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: H5i
CPAP Pressure: 14-20
CPAP Software: SleepyHead

Other Comments: Ehlers-Danlos Syndrome, Hypermobility Type; chronic sarcasm

Sex: Undisclosed
Location: western NC, USA

Post: #2
RE: Medicare Coverage
Was the no apnea events with or without a machine?

Medicare has an appeal process. I'd start that, especially if you've gotten a letter from them stating it or if the supplier has told you this.

PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

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.
12-22-2012 12:39 PM
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vsheline Offline

Advisory Members

Posts: 1,907
Joined: Jul 2012

Machine: S9 VPAP Adapt (USA Model# 36007, not better 36037 or 36067)
Mask Type: Full face mask
Mask Make & Model: F10 or SimPlus w/ 2Liners. MirageQuatro & Gecko gel pad
Humidifier: H5i
CPAP Pressure: 15 EPAP, PS 5-10
CPAP Software: ResScan

Other Comments: Marfan Syndrome, chronic bradycardia, occasional Cheyne-Stokes Respiration

Sex: Male
Location: California, USA

Post: #3
RE: Medicare Coverage
(12-22-2012 12:18 PM)apnea earlybird Wrote:  I have had sleep apnea for 26 years. I cannot fall asleep without the cpap being at proper pressure. Therefore, when I had my most recent sleep study I showed no apnea episodes. According to the most recent Medicare rules this means I do not have apnea and they will not pay for a new machine or any supplies. What do I do now? Any suggestions? Has anyone else run afoul of the new Medicare rules?

Hi apnea earlybird, welcome to the forum!

If you do not have a copy of the Sleep Study report, you are entitled to one and should ask for one.

You will of course have a hard time falling asleep with much less than the 17 cmH2O pressure you are used to.

I think you will need to appeal the denial of coverage, pointing out that the sleep study was improperly done (if there was no baseline test done *without* PAP) and did *not* show that PAP treatment was not needed. Instead at most it only showed that no apneas occurred when using PAP, and that PAP may be needed to avoid apnea events. It cannot be used to conclude that PAP is not needed. If the first appeal is denied, hang in there and appeal again at the next higher level. Hopefully, your doctor will be assisting you in all this.

Perhaps you can request a home titration for a month using an Auto machine (a model for which you can look at the data using your software), with its max pressure set above 17 and its minimum pressure set not lower than maybe 10 for first few days or until you are used to it, then progressively lowering the minimum pressure in steps of 2 cmH2O each few days until apneas start showing up.

Also, were you sleeping on your back at all during the Study? That is a common cause of more apnea events, and if you did not sleep on your back a significant amount of time during the Sleep Study, that may be another reason you could point out the Study was invalid, because (at least in the USA, I think) for the results to be valid, a certain amount of time during the Sleep Study should be spent sleeping on your back (in the "supine" position).

Another path may be to pick up a used machine from Supplier #2 on the supplier list, if you need to pay out of pocket.

Best of luck to you in your efforts to get all this straightened out. Take care,
--- Vaughn

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 12-22-2012 02:28 PM by vsheline.)
12-22-2012 02:09 PM
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Ugly Offline

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Posts: 568
Joined: Oct 2012

Machine: ResMed S9 AutoSet
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage Micro
Humidifier: ResMed H5i
CPAP Pressure: 7-14
CPAP Software: ResScan SleepyHead

Other Comments: Hydrocephalus, myopia, depression, chronic ugliness, stupidity, tinnitus, mixed sleep apnea.

Sex: Male
Location: Barrie Ontario Canada

Post: #4
RE: Medicare Coverage
(12-22-2012 12:18 PM)apnea earlybird Wrote:  I have had sleep apnea for 26 years. I cannot fall asleep without the cpap being at proper pressure. Therefore, when I had my most recent sleep study I showed no apnea episodes. According to the most recent Medicare rules this means I do not have apnea and they will not pay for a new machine or any supplies. What do I do now? Any suggestions? Has anyone else run afoul of the new Medicare rules?

26 years Huh then your visit here is long overdue. And I thought I was the one with the longest duration. Welcome The obvious news is that sleep studies are not perfect. I had one recently and it went all wrong. I had trouble breathing while falling asleep which seemed to be ignored and it rated my pressure at the same as it always was.
That was too much for me to bear and I pleaded with my otolaryngologist for a follow up appointment. I borrowed an auto CPAP from VitalAire, my service provider and it showed that the sleep study was way off. Like I wasn't the only one asleep there if you know what I mean. Oops After keeping concise records for the three weeks I had the machine it was obvious I was all over the place with my CPAP pressure needs. I forwarded this information to VitalAire and to my family doctor and finally I got an appointment again.

So what I mean is, a single sleep study is not always reliable! Ohwell It's been said, probably quite often here, that you know yourself better than anyone else. I had to bug people (some hard evidence did help) until they listened. I hope you can do the same. It seems some want the easy way out rather than giving a proper diagnosis. Like what is this world coming to? crygreen So don't give up and I hope someone has enough brains to listen for once.
12-22-2012 02:12 PM
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trish6hundred Offline

Advisory Members

Posts: 6,430
Joined: May 2012

Machine: Resmed S9 AutoSet for Her
Mask Type: Full face mask
Mask Make & Model: Fisher & Paykel Simplus
Humidifier: H5i Heated Humidifier
CPAP Pressure: 10 - 7-20 Cm H2O
CPAP Software: Not using software

Other Comments: I started CPAP in 2008. Totally blind since birth.

Sex: Female
Location: Missouri, USA

Post: #5
RE: Medicare Coverage
Hi apnea earlybird,
WELCOME! to the forum.!
What everyone has said so far.
Best of luck to you during this very trying time.

trish6hundred
12-22-2012 02:43 PM
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hunningsedaniel Offline

Preferred Members

Posts: 28
Joined: Dec 2012

Machine: S9 VPAP Auto
Mask Type: Full face mask
Mask Make & Model: fisher & pakal flexifit 432 Humidifier: H5i
Humidifier: H5i
CPAP Pressure: 14 - 21 cm H2O PS=4
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: United States

Post: #6
RE: Medicare Coverage
(12-22-2012 02:43 PM)trish6hundred Wrote:  Hi apnea earlybird,
WELCOME! to the forum.!
What everyone has said so far.
Best of luck to you during this very trying time.
Does anyone know how often Medicare will pay to replace the seal and cushion on my mask?
12-22-2012 07:58 PM
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vsheline Offline

Advisory Members

Posts: 1,907
Joined: Jul 2012

Machine: S9 VPAP Adapt (USA Model# 36007, not better 36037 or 36067)
Mask Type: Full face mask
Mask Make & Model: F10 or SimPlus w/ 2Liners. MirageQuatro & Gecko gel pad
Humidifier: H5i
CPAP Pressure: 15 EPAP, PS 5-10
CPAP Software: ResScan

Other Comments: Marfan Syndrome, chronic bradycardia, occasional Cheyne-Stokes Respiration

Sex: Male
Location: California, USA

Post: #7
RE: Medicare Coverage
(12-22-2012 07:58 PM)hunningsedaniel Wrote:  Does anyone know how often Medicare will pay to replace the seal and cushion on my mask?

Hi hunningsedaniel, welcome to the forum!

Check out our wiki. For info on Medicare in the USA, start here:
http://www.apneaboard.com/wiki/index.php...6_Medicare

Take care,
--- Vaughn

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
12-22-2012 08:10 PM
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zonk Offline

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Posts: 7,908
Joined: Feb 2012

Machine: A10 AutoSet
Mask Type: Nasal mask
Mask Make & Model: Activa LT
Humidifier: Integrated /ClimateLineAir
CPAP Pressure: 9/13
CPAP Software: ResScan

Other Comments: CPAP since Nov 2010

Sex: Male
Location: Australia

Post: #8
RE: Medicare Coverage
(12-22-2012 07:58 PM)hunningsedaniel Wrote:  Does anyone know how often Medicare will pay to replace the seal and cushion on my mask?
1 full face mask per 3 month and 1 full face cushion per month
http://www.healthcare.philips.com/pwc_hc..._Hints.pdf
12-22-2012 08:16 PM
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