Very Strange Indeed

[Donna]

I was diagnosed with severe OSA in 2011 and have been on CPAP since with a setting of 10. Recently when I called my DME for supplies, I was told I needed a new order now that my insurance has changed to Medicare. A call to my Pulmonologist and an office visit confirmed that Medicare requires a new sleep study and a new phycian order because Medicare coverage criteria is entirely different. Last night I checked into a sleep center for my ordered test. The sleep tech was in and out of my room every few minutes all night adjusting leads or requesting that I change position. To make a long story short, I slept very little if at all. This morning I was informed by the sleep tech that I didn't meet the criteria to qualify for CPAP under Medicare guidelines. I exhibit all symptoms of OSA to include severe headaches, elevated BP, extreme tiredness, etc. when I skip a night of CPAP and these symptoms correct with use. My Doctor has said that OSA is a lifetime event. How can accurate sleep study be obtained without sleep? Has anyone else experienced this? Have you found Medicare to be more stringent with criteria than other insurances? I am shocked by what just happened!

[KSMatthew]

My original sleep study was similar to yours - very little sleep and a lot of interruptions. But I, and probably you, got just enough unbroken sleep for there to be something to record.

I don't know anything about different requirements - but if you have an AHI of < 5 then you don't have OSA (I am pretty sure that anything less that 5 events per hour is considered "normal".) You should be able to get the results and see your AHI score. And I'm not sure I would rely on the advice of a technician.

As far as it being "lifetime", not always. Losing weight has a chance at minimizing OSA.

[Dormeo]

You have a right to be provided with a written copy of the report on your sleep study. I strongly recommend that you get a copy, given your questions. If you’d like to follow up further here, you could post the study so the resident experts could take a look. If you do that, be sure to black out identifying information first.

[Lee Rilea]

My wife has had apnea for a couple of decades. She went on Medicare last fall and nothing has been said.

[Donna]

On my original sleep study, my AHi is 30.7. I have a copy of it. With CPAP, pressure setting of 10, my AHI hovers around 2.0 per Sleepyhead.

[Dormeo]

Donna, do you yet know what your AHI was in the recent sleep study?

[Donna]

No, I haven't seen results from last night's study yet. Although the sleep tech was very verbal about my lack of qualifications, he didn't tell me what the AHI was. But again, wouldn't sleep be required for results to be obtained?

[Dormeo]

Once you see the report, you should be able to see what their data say that you got by way of sleep. Data about your brain waves would perhaps be part of what they’d go on. The technician may have had his personal perspective and opinions on things, but it’s the study itself you need to know about. I really hope it’s available to you soon. You’re in a lot of suspense as things stand now, and that’s rough. Keep us posted.

[bluesboybob]

If you have a follow-up scheduled with your pulmonologist to review the study results I would try not to worry too much until that happens. I also had a recent sleep study because I went on Medicare. It felt like a disaster to me because my perception was that I never slept and the tech was negative about the results. It was supposed to be a split night study but we never even got to the part where I would wear a mask. This was after 15+ years as a compliant CPAP user with my most recent study showing an AHI of 74. I was freaking out about it because my old machine was 12 years old and all I wanted was a new machine. When I had my follow-up appointment the doctor ordered a new auto bilevel machine with the same settings as my old machine. All ended well. The lab tech does not make the final decision.

[Sleeprider]

Donna, my understanding of Medicare is that a new test is not required, provided a PSG diagnostic test is available to demonstrate the need for CPAP. Many people do not retain copies of their tests or cannot obtain a copy from many years ago. In those cases a new study is generally required. If you had a copy of your previous test, you might have avoided this one. Medicare does not require individuals with documented diagnosis of OSA to be retested simply because they transition into Medicare. The first step is to ensure your supplier is enrolled to provide supplies through Medicare by checking the Supplier directory: https://www.medicare.gov/supplierdirectory/search.html In most cases, if you have documentation of your OSA and an existing CPAP machine, a new diagnosis is not required. Future machines and supplies are covered under Medicare rules for replacement interval, and a new machine will be subject to rental for 13 months, after which you will own it.

The best thing to do is to call Medicare and get clarification of the actual rules to document your existing OSA and try to get this latest test thrown out. Most provider DMEs and doctors do not know these rules or the exceptions. It is very hard to get clear answers. If you have a copy of your original diagnostic study, you are probably okay. Once you get a written copy of the the most recent study, we can help you to identify any errors that may have ocurred and might justify re-testing.