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still hoping to qualify for medicare-need advice - Printable Version

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still hoping to qualify for medicare-need advice - eajeff - 02-25-2020

So now that I am home (I was traveling before when I wrote prior messages)  I went back to my overnight sleep study results done in 2016(see attached)--the one where my pulmonologist had started me on cpap (supposed to covered under medicare), --only to find that after 6 weeks the machine was repossessed because medicare did not cover it after all.  And pulmonolgist gave me a refurb machine I have used for almost 4 years  Attached is page from sleep study.  Is it your opinion that at that time, I had such "mild" sleep apnea that it is no surprise medicare ultimately turned me down?.  Wonder if it is even worthwhile for me to pursue a home sleep study now?


RE: still hoping to qualify for medicare-need advice - bonjour - 02-25-2020

If that was denied someone doesn't know that getting kicked in the ribs every 2 minutes the entire night is not good. RERAs are a series of flow limits that end in arousal. That is very disrupting to your sleep.


RE: still hoping to qualify for medicare-need advice - 70sSanO - 02-25-2020

I’ll post the Medicare requirements again.

A positive test for OSA is established if either of the following criterion using the Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:
AHI or RDI greater than or equal to 15 events per hour, or
AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.

In my opinion, to qualify you must first see a doctor BEFORE YOUR SLEEP STUDY and complain about daytime sleepiness, insomnia and/or any of the other symptoms listed above.

Have that doctor document it and refer you for a sleep study.

You need to make sure the study provides the RDI which includes RERA’s. Medicare will base qualifications on RDI, but if your study only provides AHI, that could be a problem.

I think you need to find a doctor and sleep center that are both familiar with the Medicare requirements.

Also don’t take any shortcuts...
1. Symptoms documented.
2. RDI sleep study.
3. Provide documentation to DME.

Good luck,

John


RE: still hoping to qualify for medicare-need advice - srlevine1 - 02-26-2020

It is my understanding that the key Medicare requirement is "medical necessity." And that an aggressive doctor's report of impairment related to sleep can be used to challenge a denial based on raw numbers that do not reflect how the patient feels or the impact on their life. Do you have any co-morbidities (other conditions), does your oxygen drop during sleep? Are you a professional driver, private pilot, or in some other class that required medical certification? Is your neck size greater than 17-inches? High BMI?

Another way that might possibly work is to rent a machine with data capability, download OSCAR, prepare a report, upload the report to the forum -- and see if any forum members spot anything in the data that might be used to justify further medical action.

Of course, following 70sSanO's advice is a prudent course of action.

Best of luck.

Steve


RE: still hoping to qualify for medicare-need advice - slowriter - 02-26-2020

Just FYI, you were diagnosed with mild OSA, but you have moderate (or worse) UARS.

My understanding from my sleep doc is Medicare doesn't recognize UARS, so per others, the medical justification is mild OSA with high RDI.


RE: still hoping to qualify for medicare-need advice - eajeff - 03-08-2020

I finally was able to speak with my PCP tonight  and he is willing to provide a script for a home study.   I just talked to him on the phone and will discuss in further detail so he can document symptoms (daytime sleepiness).  He said he has  a DME he usually uses  although I believe he will let me use whoever I want.  I will find out before he uses his preferred DME  to make sure they test RDI with RERA's.  Do you think the DME matters so long as they take medicare and test for RDI?


RE: still hoping to qualify for medicare-need advice - dmeRT - 03-11-2020

(03-08-2020, 08:52 PM)eajeff Wrote: I finally was able to speak with my PCP tonight  and he is willing to provide a script for a home study.   I just talked to him on the phone and will discuss in further detail so he can document symptoms (daytime sleepiness).  He said he has  a DME he usually uses  although I believe he will let me use whoever I want.  I will find out before he uses his preferred DME  to make sure they test RDI with RERA's.  Do you think the DME matters so long as they take medicare and test for RDI?

that part about "...I just talked to him on the phone..."  is going to be a problem with medicare.  Medicare requires a face to face visit, not a phone call.  so anything you get done before a "face to face" appointment will be for naught.

Also, from your first study that showed ahi 1.4 and rdi of 29.  that meets medicare guidelines as long as there is medical documentation of your sleep issues.  i.e. tiredness, or other sleep related issues.


RE: still hoping to qualify for medicare-need advice - SideSleeper - 03-11-2020

For those members with more experience, would it be better for him to get a full house sleep study rather than a home study which leaves out some critical information? Medicare will pay for this--it depends on what secondary insurance he has and what his cost will be.


RE: still hoping to qualify for medicare-need advice - Sleeprider - 03-11-2020

(03-11-2020, 02:30 PM)SideSleeper Wrote: For those members with more experience, would it be better for him to get a full house sleep study rather than a home study which leaves out some critical information?   Medicare will pay for this--it depends on what secondary insurance he has and what his cost will be.

Medicare will recognize PSG whether it is a home sleep study or clinical, but to document RDI a clinical sleep study is the only way to go.  Covered home studies much include a minimum number of channels of analysis, but since EEG is rarely includied, it simply cannot document RDI and will actually underestimate AHI, since sleep cannot be determined.  In this case, I agree with your concerns.


RE: still hoping to qualify for medicare-need advice - dmeRT - 03-11-2020

I have seen home sleep studies that report a RDI.  but in my opinion... with his low AHI, it would be best to have an in lab study.