RE: Medicare Denial
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.