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Medicare Service Refusal
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vsheline Online

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Posts: 1,908
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: #11
RE: Medicare Service Refusal
(10-04-2015 07:37 PM)Mike1953 Wrote:  
(10-04-2015 04:22 PM)DariaVader Wrote:  not sure what your point is. that is still the coverage for cpap rather than asv.

It is the same. https://www.cms.gov/Outreach-and-Educat ... 905064.pdf

Hi Mike1953,

Bilevel machines which have the "Backup Rate" feature (like ASV and ST therapy modes) have a different reimbursement code and have additional requirements for coverage.

I don't remember the precise requirements, but (from memory) the USA Medicare requirements for coverage of a machine with a backup respiration rate for treating central events are approximately as listed below:

1. The doctor must obtain preauthorization for a special ASV or ST titration. Obtaining preauthorization will require documentation that central apnea events are occurring at a rate of at least 5 per hour when the patient is using standard 'PAP therapy to treat obstructive events, and the central events are the dominant remaining problem. That is, when treated by standard 'PAP machine central events outnumber obstructive events, and the CAI is, all by itself, at least 5.

2. The ASV or ST titration must identify pressure settings at which the ASV therapy or ST therapy adequately prevents/treats the problem.

If any of the requirements are not met then I think Medicare will not cover any of the costs for the machine and supplies until all requirements are met.

If one has financial resources to purchase machine and supplies out of pocket, then only the doctor's prescription is needed.

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: 10-04-2015 10:09 PM by vsheline.)
10-04-2015 09:19 PM
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Mike1953 Offline

Preferred Members-2

Posts: 134
Joined: Aug 2014

Machine: Resmed S9 Escape Auto
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
Humidifier: Resmed Hi5
CPAP Pressure: 12
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Kansas USA

Post: #12
RE: Medicare Service Refusal
(10-04-2015 09:19 PM)vsheline Wrote:  
(10-04-2015 07:37 PM)Mike1953 Wrote:  
(10-04-2015 04:22 PM)DariaVader Wrote:  not sure what your point is. that is still the coverage for cpap rather than asv.

It is the same. https://www.cms.gov/Outreach-and-Educat ... 905064.pdf

Hi Mike1953,

Bilevel machines which have the "Backup Rate" feature (like ASV and ST therapy modes) have a different reimbursement code and have additional requirements for coverage.

I am not sure what are the exact requirements, but (from memory) the requirements are approximately as listed below:

1. The doctor must obtain preauthorization for a special ASV or ST titration. Obtaining preauthorization will require documentation that central apnea events are occurring at a rate of at least 5 per hour when the patient is using standard 'PAP therapy to treat obstructive events, and the central events are the dominant remaining problem. That is, when treated by standard 'PAP machine central events outnumber obstructive events, and the CAI is, all by itself, at least 5.

2. The ASV or ST titration must identify pressure settings at which the ASV therapy or ST therapy adequately treats/prevents the problem.

If the requirements are not met then I think Medicare will not cover any of the costs for the machine and supplies until the requirements are met.

If one has financial resources to purchase machine and supplies out of pocket, then only the doctor's prescription is needed.

Which is exactly what I have posted. Medicare may cover it
if you meet in person with your doctor, and your doctor
documents in your medical record that the CPAP therapy is
helping you. It is all in the paperwork trail and someone has not completed it properly. I say again, it is just that simple. Paperwork must be done properly.

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
10-04-2015 10:01 PM
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vsheline Online

Advisory Members

Posts: 1,908
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: #13
RE: Medicare Service Refusal
(10-04-2015 10:01 PM)Mike1953 Wrote:  Which is exactly what I have posted.

Hi Mike1953,

https://www.cms.gov/Outreach-and-Educat ... 905064.pdf is an abbreviated web address which does not work.

(When posting a link, best to copy the full address from the browser address bar.)

Edit:
A working link is
https://www.cms.gov/Outreach-and-Educati...905064.pdf

But the article only talks about requirements for coverage of machines for treatment of obstructive sleep apnea.

I did a quick search but was unable to find the exact requirements for coverage of machines with a backup respiration rate needed for treatment of central or complex sleep apnea.

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: 10-05-2015 12:44 AM by vsheline.)
10-04-2015 10:38 PM
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surferdude2 Offline

Advisory Members

Posts: 1,077
Joined: Jul 2014

Machine: ResMed S9 AutoSet
Mask Type: Full face mask
Mask Make & Model: Mirage Quattro & Optilife
Humidifier: ResMed H5i @ #3 if nose breathing & #5 if mouth breathing
CPAP Pressure: 12 ~ 20 & 11 ~12 if nasal mask
CPAP Software: ResScan SleepyHead

Other Comments: Late stage 2 emphysema

Sex: Male
Location: Mousetown, Southern Illinois

Post: #14
RE: Medicare Service Refusal
I think it is supposed to be this:

https://www.cms.gov/Outreach-and-Educati...905064.pdf

edit: Looks like you already got it. Smile
(This post was last modified: 10-04-2015 10:56 PM by surferdude2.)
10-04-2015 10:55 PM
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vsheline Online

Advisory Members

Posts: 1,908
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: #15
RE: Medicare Service Refusal
(10-04-2015 10:38 PM)vsheline Wrote:  I did a quick search but was unable to find the exact requirements for coverage of machines with a backup respiration rate needed for treatment of central or complex sleep apnea.

I think this covers the full requirements for a "E0471" device (meaning a device with a backup rate). Rather dense hard-to-follow language in some spots, though.

http://www.medicarenhic.com/viewdoc.aspx?id=2826

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: 10-04-2015 11:21 PM by vsheline.)
10-04-2015 11:17 PM
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Mike1953 Offline

Preferred Members-2

Posts: 134
Joined: Aug 2014

Machine: Resmed S9 Escape Auto
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
Humidifier: Resmed Hi5
CPAP Pressure: 12
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Kansas USA

Post: #16
RE: Medicare Service Refusal
And for the last time OP's doctor needs to word the paperwork exactly to what is needed for the OP or Medicare will not cover it. Which is again what I have posted several times. Good night, Good morning or what ever time zone your in.

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
10-04-2015 11:27 PM
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