05-27-2025, 09:03 PM
Need Help Buying CPAP supplies in spite of uncooperative PCP
Hi all,
For many years I have been using Medicare Advantage insurance to buy CPAP supplies. The usual arrangement has been that the supplier has a contract with my insurance carrier and has agreed to accept Medicare allowable as full payment. When I order supplies, I pay the supplier 20% of Medicare allowable while the insurance carrier pays 80%.
Before 2025, I have always needed an "authorization" to allow the supplier to sell supplies to me under Medicare Advantage rules. My authorization has always been an "order" or a "letter of medical necessity" signed by my PCP that documents my OSA diagnosis. My PCP in turn always had a copy of a sleep study that officially diagnosed my obstructive sleep apnea. Every year I had to ask my PCP to renew the authorization and send it to the supplier, but that seems to have changed. To be clear about the supplies I am buying, I am talking about masks and headgear and the like, not CPAP machines or any kind of equipment.
Here's the short version of my long struggle with the Apnea Demon: (1) I am in my 80s, (2) I was first diagnosed with OSA in 1992 - almost 25 years ago, (3) I have had about 5-6 sleep studies since 1992, and all of them confirmed the initial diagnosis of OSA, (4) the most recent sleep study, which took place in 2017, diagnosed both OSA and CSA with an overall AHI of about 75 when no treatment was in effect. Since the 2017 titration study failed to get my AHI below 30 with various BIPAP and ASV settings, the sleep docs did not prescribe a new machine. I used a Devillbiss Intellipap 2 (Auto-adjusting CPAP) at that time. I bought a Resmed AirSense 10 in 2022 and finally in the spring of 2023, I bought an AirCurve 10 ASV with my own money. In about 4-5 months, I brought my AHI down under 5 with the help of Resmed ASV and OSCAR.
My problem today is that I have a new PCP and when I sent him a message saying that I would soon need a signed authorization to buy CPAP supplies, he bristled and suggested that I should get a sleep study to base it on. I have several other health issues now that are more important to me than sleep apnea, and although I don't want to spend time and money on a sleep study, my primary caregiver might deny access to CPAP supplies (which I do need) using a non-existent need for a sleep study as a faux preliminary requirement. I hope this won't happen, but if it does, I want to know what I can do to dispute or override the doctor's non-authorization. I think my eligibility to buy CPAP supplies under Medicare Advantage rules is established by my existing diagnosis of OSA all by itself and so if a doctor refuses to authorize my Medicare Advantage supply purchases it amounts to denial of needed, contracted, and paid for care used to force me to buy something I don't need or want (a sleep study). It's more like coercion and extortion than health care.
I'd appreciate any help understanding Medicare's rules regarding CPAP supply authorizations (can a doctor just arbitrarily add his own requirements, like a new sleep study even if Medicare doesn't require a new study), I'd also like to know how to find details of my insurance plan's rules over and above their standard benefit summaries, and what I might be able to do to dispute and override a bad decision if that's how things work out.
I may be asking for more than is practically possible, but thanks for any info you can provide.
For many years I have been using Medicare Advantage insurance to buy CPAP supplies. The usual arrangement has been that the supplier has a contract with my insurance carrier and has agreed to accept Medicare allowable as full payment. When I order supplies, I pay the supplier 20% of Medicare allowable while the insurance carrier pays 80%.
Before 2025, I have always needed an "authorization" to allow the supplier to sell supplies to me under Medicare Advantage rules. My authorization has always been an "order" or a "letter of medical necessity" signed by my PCP that documents my OSA diagnosis. My PCP in turn always had a copy of a sleep study that officially diagnosed my obstructive sleep apnea. Every year I had to ask my PCP to renew the authorization and send it to the supplier, but that seems to have changed. To be clear about the supplies I am buying, I am talking about masks and headgear and the like, not CPAP machines or any kind of equipment.
Here's the short version of my long struggle with the Apnea Demon: (1) I am in my 80s, (2) I was first diagnosed with OSA in 1992 - almost 25 years ago, (3) I have had about 5-6 sleep studies since 1992, and all of them confirmed the initial diagnosis of OSA, (4) the most recent sleep study, which took place in 2017, diagnosed both OSA and CSA with an overall AHI of about 75 when no treatment was in effect. Since the 2017 titration study failed to get my AHI below 30 with various BIPAP and ASV settings, the sleep docs did not prescribe a new machine. I used a Devillbiss Intellipap 2 (Auto-adjusting CPAP) at that time. I bought a Resmed AirSense 10 in 2022 and finally in the spring of 2023, I bought an AirCurve 10 ASV with my own money. In about 4-5 months, I brought my AHI down under 5 with the help of Resmed ASV and OSCAR.
My problem today is that I have a new PCP and when I sent him a message saying that I would soon need a signed authorization to buy CPAP supplies, he bristled and suggested that I should get a sleep study to base it on. I have several other health issues now that are more important to me than sleep apnea, and although I don't want to spend time and money on a sleep study, my primary caregiver might deny access to CPAP supplies (which I do need) using a non-existent need for a sleep study as a faux preliminary requirement. I hope this won't happen, but if it does, I want to know what I can do to dispute or override the doctor's non-authorization. I think my eligibility to buy CPAP supplies under Medicare Advantage rules is established by my existing diagnosis of OSA all by itself and so if a doctor refuses to authorize my Medicare Advantage supply purchases it amounts to denial of needed, contracted, and paid for care used to force me to buy something I don't need or want (a sleep study). It's more like coercion and extortion than health care.
I'd appreciate any help understanding Medicare's rules regarding CPAP supply authorizations (can a doctor just arbitrarily add his own requirements, like a new sleep study even if Medicare doesn't require a new study), I'd also like to know how to find details of my insurance plan's rules over and above their standard benefit summaries, and what I might be able to do to dispute and override a bad decision if that's how things work out.
I may be asking for more than is practically possible, but thanks for any info you can provide.
