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Medicare and 2nd machine
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AirSign Offline

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Posts: 85
Joined: Mar 2015

Machine: ResMed Airsense A10 for her
Mask Type: Nasal pillows
Mask Make & Model: Nuance / Airfit P10
Humidifier: Airsense A10
CPAP Pressure: 9-16, average under 14
CPAP Software: SleepyHead

Other Comments: Seasons here: Wintah, Mud, Road Repair, Wintah

Sex: Female
Location: Road Repair Season, New England

Post: #1
Medicare and 2nd machine

About getting my new APAP machine . . .

Just got a call from Dr's office that DME wants a statement from them that CPAP is benefitting me.

MD is new -- only saw him once, so nurse said DME says it's OK for me to say that CPAP is benefitting me.

Nurse said this is because of Medicare rules.
If the MD writes the prescription, that's not enough. He also has to certify that the therapy I've been using for 6 years every night is benefitting me?

My first response was to say "well, I'm still alive."

Has anyone else had this required from Medicare for a second machine after 5+ years?
03-16-2015 12:30 PM
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OpalRose Offline

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Posts: 3,170
Joined: Nov 2014

Machine: PR System One REMstar Auto 560 with A Flex
Mask Type: Nasal pillows
Mask Make & Model: AirFit P10 For Her
Humidifier: REMStar heated humidifier with heated hose
CPAP Pressure: Auto Cpap 10-13 AFLEX 1
CPAP Software: SleepyHead EncoreBasic

Other Comments: Started CPAP Therapy October 23, 2014

Sex: Female
Location: Northeast Ohio, USA

Post: #2
RE: Medicare and 2nd machine
(03-16-2015 12:30 PM)AirSign Wrote:  
About getting my new APAP machine . . .

Just got a call from Dr's office that DME wants a statement from them that CPAP is benefitting me.

MD is new -- only saw him once, so nurse said DME says it's OK for me to say that CPAP is benefitting me.

Nurse said this is because of Medicare rules.
If the MD writes the prescription, that's not enough. He also has to certify that the therapy I've been using for 6 years every night is benefitting me?

My first response was to say "well, I'm still alive."

Has anyone else had this required from Medicare for a second machine after 5+ years?

AirSign,
It sounds logical that Medicare would want a statement from your Doctor. The DME probably has to submit that statement to Medicare.
Even if your Doctor is new, he should be the one to submit this statement to DME.
OpalRose

OpalRose
03-16-2015 01:01 PM
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justMongo Offline

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Posts: 3,849
Joined: Sep 2013

Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #3
RE: Medicare and 2nd machine
Medicare is pulling out the medical necessity card to the detriment of beneficiaries.
After over 10 years of testing blood glucose 5 times a day, they just denied my order.
I appealed -- they denied. CMS is run by a private contractor, Noridian Systems.
Medicare is immune from legal action -- Noridian is not.
Noridian and their employees can all be sued.

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.
03-16-2015 01:07 PM
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Clay L Online

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Posts: 56
Joined: Feb 2012

Machine: PR System One Auto
Mask Type: Full face mask
Mask Make & Model: Respironics Amara View minimum contact full face mask
Humidifier: PR System One Series 60
CPAP Pressure: 11.5
CPAP Software: SleepyHead EncoreViewer

Other Comments: We now live in Palisade CO after living full time in a motor home and following the sun for 12 years

Sex: Male
Location: Palisade CO

Post: #4
RE: Medicare and 2nd machine
Medicare required a Doctor - can be a primary care doc does not have to be a sleep doc - to certify that CPAP is benefiting my wife. She got her machine about a year ago. I got my current one several years ago and that was not required then.

The doc said that he had to actually see her, he was willing to just make the certification but Medicare wouldn't accept it. We took a Sleepyhead summary page to show him and he put that in her file.
(This post was last modified: 03-16-2015 03:09 PM by Clay L.)
03-16-2015 03:06 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: #5
RE: Medicare and 2nd machine
Hi AirSign

As you have been using your machine "RemStar Plus" for the last 5 years, the machine report compliance data, you can take the machine or/and data card to the doctor so he/she can verify your compliance
My understanding, successful compliance is that you're using the machine at least 4 hours each night 70% of he time or something like that

As for the machine, ask the doctor to write the prescription for the machine of your choice and "dispense as written" to avoid any confusion and end up with the wrong machine which is something happen quite often, also keep a copy of the prescription for your self, you never know when you might need it

Best of luck
03-16-2015 03:42 PM
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Mike1953 Offline

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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: #6
RE: Medicare and 2nd machine
Medicare may allow a new machine every 5 years but each time a new machine is issued you have to show the compliance and meet face to face with your Dr. who has to file that it is a benefit to your health. Then you have to meet with him within the 90 days compliance for Medicare to continue to pay for your new machine. Compliance is at least 4 hours each night for 70% of the time during the first 90 days of using a new machine.
Medicare and most private insurers cover scheduled replacements of all mask parts and other supplies (including CPAP machines, but we’ll talk about those in an upcoming blog post). Ask your insurance provider how often it will cover the replacement of each part. Your equipment supplier can answer any questions about this and even help you fill out and process any necessary forms. Based on Medicare coverage, we suggest that you replace:
Every month
• Mask cushions and/or nasal pillows
• CPAP machine filters
Every 3 months
• Mask frame (not including the headgear)
• CPAP tubing
Every 6 months
• Mask headgear
• Chin strap (if applicable)
• Humidifier water tub

For free Medicare assistance for your state check out this page. http://www.seniorsresourceguide.com/directories/National/SHIP/
or here http://www.medicareinteractive.org/
03-16-2015 06:32 PM
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AirSign Offline

Preferred Members

Posts: 85
Joined: Mar 2015

Machine: ResMed Airsense A10 for her
Mask Type: Nasal pillows
Mask Make & Model: Nuance / Airfit P10
Humidifier: Airsense A10
CPAP Pressure: 9-16, average under 14
CPAP Software: SleepyHead

Other Comments: Seasons here: Wintah, Mud, Road Repair, Wintah

Sex: Female
Location: Road Repair Season, New England

Post: #7
RE: Medicare and 2nd machine
Thanks
Thanks everyone. I ran out of my allotted number of posts or I would have responded sooner.

Am still waiting for my January titration results.

My new pulmonologist MD is relatively new to the USA, and perhaps has not much experience with Medicare.

As for replacements on everything else to now, my DME has been very conscientious and prompt.

Second night with Wisp went better.

All in all, things seem to be moving in the right direction.

Smile
(This post was last modified: 03-16-2015 09:45 PM by AirSign.)
03-16-2015 09:37 PM
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Homerec130 Offline

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Posts: 444
Joined: Mar 2012

Machine: Philips/Resperonics BiPAP auto SV Advanced System One (950P)
Mask Type: Full face mask
Mask Make & Model: ResMed Quatro FX
Humidifier: Philips Respironics System 1
CPAP Pressure: 6-16
CPAP Software: SleepyHead

Other Comments: But it is a dry heat.

Sex: Male
Location: Tucson, AZ

Post: #8
RE: Medicare and 2nd machine
(03-16-2015 06:32 PM)Mike1953 Wrote:  Medicare may allow a new machine every 5 years but each time a new machine is issued you have to show the compliance and meet face to face with your Dr. who has to file that it is a benefit to your health. Then you have to meet with him within the 90 days compliance for Medicare to continue to pay for your new machine. Compliance is at least 4 hours each night for 70% of the time during the first 90 days of using a new machine.
Medicare and most private insurers cover scheduled replacements of all mask parts and other supplies (including CPAP machines, but we’ll talk about those in an upcoming blog post). Ask your insurance provider how often it will cover the replacement of each part. Your equipment supplier can answer any questions about this and even help you fill out and process any necessary forms. Based on Medicare coverage, we suggest that you replace:
Every month
• Mask cushions and/or nasal pillows
• CPAP machine filters
Every 3 months
• Mask frame (not including the headgear)
• CPAP tubing
Every 6 months
• Mask headgear
• Chin strap (if applicable)
• Humidifier water tub

Mike,

Find it interesting that you mention the mask headgear as every 6 months and the frame every three. Both of the models I used came with the mask and headgear already assembled in a factory sealed package. Other than that, your list matches what my gov't insurance provides.

Homer
03-17-2015 12:44 PM
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PollCat Offline
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Posts: 1,576
Joined: Feb 2012

Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: ResMed AirFit P10
Humidifier: H5i Cleanable with ClimateLine
CPAP Pressure: 10 - 18
CPAP Software: SleepyHead

Other Comments: CPAP-ing since 1995; Type 2 Diabetes; Chronic Asthma; Gout

Sex: Male
Location: Westfield, IN

Post: #9
RE: Medicare and 2nd machine
I turned 65 about 5 months after I'd purchased my S9 machine. When I went to purchase new nasal pillows and headgear, Medicare wanted to know why I needed them. I politely informed them that I'd been receiving CPAP therapy since the mid-90's. However, my sleep doc still had to vouch for my need.

Now, I don't bother filing for reimbursement - it's not worth the hassle. Oh-jeez A practice I might have to alter when I need a newer machine. Shock-2


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.
03-19-2015 10:40 PM
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Nyre Offline

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Posts: 46
Joined: Mar 2015

Machine: PR System One REMStar 60 Series BiPAP autoSV Advanced
Mask Type: Full face mask
Mask Make & Model: Resmed Mirage Quattro FX
Humidifier: Builtin
CPAP Pressure: Unsure
CPAP Software: SleepyHead

Other Comments:

Sex: Male
Location: New Castle, IN

Post: #10
RE: Medicare and 2nd machine
(03-16-2015 06:32 PM)Mike1953 Wrote:  Medicare may allow a new machine every 5 years but each time a new machine is issued you have to show the compliance and meet face to face with your Dr. who has to file that it is a benefit to your health. Then you have to meet with him within the 90 days compliance for Medicare to continue to pay for your new machine. Compliance is at least 4 hours each night for 70% of the time during the first 90 days of using a new machine.
Medicare and most private insurers cover scheduled replacements of all mask parts and other supplies (including CPAP machines, but we’ll talk about those in an upcoming blog post). Ask your insurance provider how often it will cover the replacement of each part. Your equipment supplier can answer any questions about this and even help you fill out and process any necessary forms. Based on Medicare coverage, we suggest that you replace:
Every month
• Mask cushions and/or nasal pillows
• CPAP machine filters
Every 3 months
• Mask frame (not including the headgear)
• CPAP tubing
Every 6 months
• Mask headgear
• Chin strap (if applicable)
• Humidifier water tub

Very informative post. Thank you
03-20-2015 12:48 AM
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