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Medicare Denial
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Kidnap Offline

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Post: #1
Medicare Denial
I am a newbe. I don't even have my cpap yet.

Last September I had a total hip replacement on my left hip. In October I had my annual physical exam. My Hematocrit (HCT) count was 52.2 which cound indicate sleep apnea. He wanted me to take a sleep study but due to hip problems I put it off until August. The test showed AHI of 53 and SpO2 at 70%. Medicare first said I could get a AirSense™ 10 AutoSet CPAP, BUT then denied me because I didn't see my Doctor "Face to Face" within 6 months. They now want me to take the Sleep Study and titration test over. I would then probably have to pay for the first two tests out of pocket because a bureaucrat says they can't be used because of a 6 month rule. Some people say my family doctor isn't good enough I must see a Pulmonary Doctor "Face to Face" .

Has anyone else had this problem or how to get around it?

Your Friend Kidnap
09-14-2015 07:33 PM
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OpalRose Offline

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Post: #2
RE: Medicare Denial
I doubt there is a way around any Medicare rules.

When I started my therapy, I was told by my insurance that I had to see my sleep doctor/pulmonologist within 90 days. I didn't want to take the chance that Insurance would stop paying rental on my machine, so I complied with the rules.

OpalRose
09-14-2015 07:50 PM
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Sleeprider Online
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Post: #3
RE: Medicare Denial
Welcome to the forum. Medicare is kind of a beast, but if you have the support of your primary doctor, you can probably get the prescription you need. You said that you have a hemocrit of 52.2, but that is not diagnostic of OSA. It is a common complication of hormone replacement therapy and there are other causes. If you are covered for a sleep study, it is the best solution. Otherwise, a home study should be acceptable for Dx purposes for Medicate. Check with your primary care doc.

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09-14-2015 07:57 PM
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trish6hundred Offline

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Post: #4
RE: Medicare Denial
Hi Kidnap,
WELCOME! to the forum.!
I wish you much success in getting your CPAP machine, you might talk to your primary doc about this.
Hang in there for more responses to your post.

trish6hundred
(This post was last modified: 09-17-2015 07:59 PM by trish6hundred.)
09-14-2015 08:19 PM
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Mike1953 Offline

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Post: #5
RE: Medicare Denial
Here is Medicares compliance, Medicare Coverage of CPAP at Home
After the patient starts CPAP treatment at home there has to be documentation of patient compliance. This is done after 31 days but before 90 days of usage. They must have a download of the CPAP usage and a face to face re-evaluation with their physician. Their physician must document that the patients symptoms have improved. Adherence to CPAP is defined as usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of initial usage
You must comply to Medicare Compliance Policy.

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
09-14-2015 08:30 PM
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Ghost1958 Offline

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Post: #6
RE: Medicare Denial
Does not have to be a pulminoligist for the face to face.
Could be your Gp or other primary care rovider.
No idea where six months is coming from.
Face to face has to be in 90 days.
Check direct with medicare. Not the DME.
09-14-2015 08:49 PM
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on the virge Offline

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Post: #7
RE: Medicare Denial
(09-14-2015 07:33 PM)Kidnap Wrote:  I am a newbe. I don't even have my cpap yet.

Last September I had a total hip replacement on my left hip.
In October I had my annual physical exam. ....He wanted me to take a sleep study ...
I put it off until August. The test showed AHI of 53 and SpO2 at 70%. Medicare first said I could get a AirSense™ 10 AutoSet CPAP, BUT then denied me because I didn't see my Doctor "Face to Face" within 6 months.

1) I am confused. You have not started therapy because you have not gotten a CPAP machine. I don't understand the lack of a "Face to Face" with your Doctor within 6 months. There can't be a three month compliance issue because you haven't begun therapy.
2) Is the 6 month concern because your doctor ordered the sleep study last October and the study wasn't done until last month (August)? In other words the doctor's order was stale or expired (10 months after written).

If the problem is the doctor's order for the sleep study then they must be denying to pay for the study done last month. It would seem that appealing their decision might be successful with support from your doctor given the results of the study (showing AHI of 53 and SpO2 at 70%). I don't see why they would not accept the study done last month.

I'm missing something.
09-14-2015 10:30 PM
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DariaVader Offline
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Post: #8
RE: Medicare Denial
Seems like some of these bureaucratic govt agencies, insurance companies etc (or any other type of customer support organization) give different answers every time you ask. Sometimes you just keep trying until you get the answer you wanted...

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
09-14-2015 10:40 PM
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Mike1953 Offline

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Post: #9
RE: Medicare Denial
Your Dr ordered a sleep study in October of 2014 but you waited until August of 2015 to get a sleep study done. That is way more than the 6 months from the time of your first face to face. What you should have done was to see your Dr just before you went in for the study. I don't see what the confusion is all about. Then again after you start you therapy as I stated in a earlier compliance post you need to see your Dr within 90 days to prove that the therapy is working for you. Just follow the Medicare Rules and you will be fine. If you take things into your own hands you will not be in compliance with Medicare Rules.

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
09-14-2015 11:16 PM
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SaldusMiegas Offline

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Post: #10
RE: Medicare Denial
Hi Kidnap,

welcome to apneaboard forum.

When you say that Medicare denied the machine after previously approving it, we need to clarify what specific request was denied. Could it be that what was denied was a request to outright purchase a new machine of an approved make & model for lack of required documentation to demonstrate compliance and effectiveness?

My guess is the DME asked Medicare if the A10 would be covered and Medicare said yes that machine was acceptable. Then the DME submitted a purchase request and Medicare said whoa, first you have to meet the requirements. So Medicare did not change its mind. If the DME represented that to you then shame on them.

But don't worry, it's a confusing system. DMEs hire people who have to learn the system. Patients suffering severe sleep apnea are also impaired to some level with head fog and fatigue. So nobody here is probably being deceptive, there is just some confusion to sort out. Let's try and unravel it here so you understand what is required, then you can go pursue making it happen.

Medicare is not my insurance, but based on the stories of others there is a recurring scenario with Medicare that does make sense. To paraphrase what has been repeated above in different ways, that scenario goes something like this:

1. A medical need for CPAP therapy is identified in some manner that involves a sleep study and a doctor. I don't see how the date of your sleep study can be problematic for Medicare, as the study report is very recent and was certainly signed by a doctor. So the medical need for CPAP therapy has been duly established by a doctor based on a sleep study.

I believe this starts a six month clock ticking. Within six months from the study you will have to meet the other requirements (see #3 below) or else you will have to have a new study. That seems like a sensible requirement, and it seems like you have established the medical need and are now in month one of the six month window to meet the other requirements.

2. Next event is for you to get a CPAP machine but you probably won't be approved to purchase it. It is common for people to rent a machine during the compliance period and the rental is covered by Medicare. It's probably not going to be a new machine but rather a loaner.

3. From the time you get your temporary machine, you will have three months to demonstrate (via data recorded by the CPAP machine) that during any consecutive 30 day period you actually did use the machine at least four hours per night for a total of 21 out of those 30 nights (i.e. 70% of the nights which don't have to be 21 days in a row within that 30 day period). Once you have accomplished this, you meet the compliance requirement.

Three months to demonstrate one month of compliance seems reasonable. Medicare is not going to rent you a temporary machine forever without you proving that you will be compliant and use the thing.

4. Next you have a face to face meeting with your doctor who will verify the data the machine captured demonstrates 30 days of compliance, and the doc will also make a judgment call on effectiveness of the therapy, probably based on how you are feeling. When s/he writes that down, that will meet the requirement for effectiveness established during a face to face meeting.

Again, you have six months from the date of your sleep study to get your temporary machine and meet the requirements for a permanent one.

After all this, Medicare can be reasonably certain that the therapy is beneficial to you AND that you will actually use the machine. At that point with all the requirements met, they will approve the purchase of a new permanent machine for you.

This is how it seems to go for a lot of people, and not just Medicare patients. Many private insurers follow the Medicare guidelines and require patients to meet the same requirements before the insurance company will purchase a machine for a patient. Some DMEs have rent-to-own plans built specifically around these requirements, in which case a patient would get a new machine and after 13 months rent is paid, the machine belongs to the patient. If the patient fails to meet the requirements then the machine goes back to the DME (and probably becomes a temporary machine for someone else).

Bottom line is you need to clarify what precisely was denied by Medicare, and then get with your doctor (not the DME) to map out your strategy to get you a CPAP machine and meet the Medicare requirements. Then go make it happen.

I could be mistaken in the above scenario since I am not myself a Medicare patient nor provider, but I bet it's pretty close, and your doctor will know for sure what the requirements are.

hope this is helpful. Don't panic or despair. It's pretty clear you have a medical need. I would not be surprised if your doctor is willing to help expedite getting you on therapy based on the numbers you shared with us.

You just have to work through the process and meet the requirements of the process. Get your doctor involved. I would call the office and ask for help with this. They can get their insurance and DME liaisons working with the DME on your behalf to get this rolling. If it's the same doctor you mentioned above, you may not need an appointment to get this moving. You won't know until you make that call, and make sure your doc has the sleep study results from the sleep lab.

good luck kidnap. Sounds like you already had a heck of a year. Now that you have the hip surgery and physical torture, er, therapy behind you, it's time to feel better.

Saldus Miegas
09-15-2015 01:19 AM
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