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Sarcastic Dave: I find the two documents you sent a bit confusing and contradictory. Which is no surprise I guess given its dealing with a federal bureaucracy. Please consider the conclusion of both given my circumstance: I tried APAP for 3+ months and was not fully compliant
MEDICARE POLICY FOR TREATMENT OF OSA: BILEVEL QUALIFICATIONS; I can check boxes 1&2 Under box 2 I meet A. and then under B. I meet #2, that being APAP has not improved my sleep quality. The 2 choices below that I would check the NO box (I have used it for more than 3 months) which says I need a new face to face with my PCP and NO SLEEP STUDY REQUIRED. Then the second document:
BILELVEL CONVERSION PATHWAYS. i am currently after a 3 month trail. #4 in the 'footnotes" indicates that if I have failed the 12 week trial, I assume with my apap, then I need a new face to face with my PCP and a "new sleep study".
Don't this 2 scenarios contradict each other?? I think I am going to need to spend time on the phone with a Medicare rep to argue my case and see if I can succeed in getting them to cover BiPAP. Its no use arguing with the DME I don't think.
Next question: I keep reading that BIPAP is used when patients need higher pressures than cpap/apap, if I interpret that correctly. I don't need higher pressure per se. I need a more comfortable, smoother therapy. MY flow rates continue to be really rough and "I think", but my inexperience could prove me wrong, its my ragged flow rates that are proving to be the cause of my unrestful therapy. Ragged flows and sleep-wake junk?? I just want to make sure I understand how BIPAP will help me before I fight with Medicare for it.
05-17-2025, 03:10 PM (This post was last modified: 05-17-2025, 04:00 PM by SarcasticDave94.
Edit Reason: Typo edit
)
RE: Pokey49 - Therapy Thread
Here's how it works. You were qualified medically for CPAP. You have a CPAP now, so the qualifications were met so far.
Again here's the big key factor on page 1 of the Medicare chart. Did you have the CPAP less than 3 months?
If you say NO to less than 3 months, you would be required to have a NEW face to face with your doctor about bilevel, but no more sleep study. You then need to pass a new compliance 3 months and new face to face doctor visit, saying bilevel is helping.
You have done the face to face doctor visit required to proceed with bilevel, as he issued a bilevel script for it during a doctor visit discussing bilevel.
I think you've exhausted every edit possible on the AutoSet to make therapy effective, yet it's not helping enough. The next step is a more capable machine called VAuto, the bilevel.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
05-17-2025, 03:30 PM (This post was last modified: 05-17-2025, 04:01 PM by SarcasticDave94.)
RE: Pokey49 - Therapy Thread
Document 1, you say you had CPAP more than 3 months, so the No path is correct. This makes the assumption you passed compliance. You could not have kept the CPAP beyond 3 months unless you either passed compliance or bought the CPAP with cash.
Document 2 footnote 4... Wouldn't apply if you passed compliance.
The 3 month compliance I mention is equal to Medicare 12 weeks compliance.
If this DME will not issue the VAuto following this Medicare chart, you will have to return the CPAP and go to a new DME that will follow Medicare rules.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
I think I fell out of compliance the last 2 weeks of month 3. So I’m concerned I’m going end up high and dry with no therapy unless I end up having to pay for a machine myself.
I’ve got an appointment with my PCP this week to ask if he will write a Rx saying I need Bipap. This will be in addition to the Rx for bipap from the doc who read my sleep study . I’m also going to call Medicare and ask to speak to a DME supervisor level person about all this.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
You should be good to go if you have the prescription for BiPAP. Have the DME get the prescription, fill it, and then exchange the CPAP for the BPAP they acquired to fill the prescription.
I only give suggestions from experience as a fellow CPAP user, not professional advice.
The DME has the prescription for BIPAP. The gal I talked with said I was only 67% compliant the last 22 days which I am not surprised as I've had LOTS of trouble despite my efforts. She indicated I may have to return the APAP or pay for it. I will return it before I pay for it. I can get the BIPAP there with my RX, no problem, but per the DME I will have to pay retail, she thinks. I talked with Medicare briefly last week and explained the situation and it sounded like that they would not pay for the BIPAP because I fell under the wire the last month. I am going to call them again Monday. I have an appointment Tuesday with my PCP to see if he will write a 2nd RX in an effort to get the DME & Medicare to work with me hoping medical necessity trumps thier one size fits all rules. I have tried every conceivable setting with the APAP and I still get poor sleep despite having a low AHI.
Please see last nights Oscar below. Again a low AHI, but lousy sleep quality. I awoke around 2am (actually 3, timeline is an hour behind) and was air starved and had to remove the mask to breathe. But then spontaneously fell asleep again which accounts for the large blank space with no data until about 4:15 when I put the mask back on, then had a bathroom break, then back to sleep until about 630
The 2nd screen shot is showing just before I woke up about 2am. I was having pretty steady flow rate, I think, then bam all those CAs. I do note the large leaks this time. Tonight I am going to do an all night oximetry. I think my O2 is zigging and zagging throughout the night and I am waking up with a headache. I spot checked it a few times last night. It would be 98, then 94, then 96, then 93, then 97 etc. Its like the APAP and my body are fighting with each other. I'm scheduled to see the NP at the pulmonary/sleep office that my cariologist referred me to, but not until June 5. I dont know what all is going on, but its worrisome.
DME should not worry about payment for a BiPAP. If you have a prescription, they should fill it, and file with Medicare for charges explaining why BiBAP is needed. It should be covered. If you are not compliant with the BiPAP then coverage will cease and you either have to pay for the machine or return it. Same with APAP.
I only give suggestions from experience as a fellow CPAP user, not professional advice.
Let us know how the call with Medicare goes down tomorrow. I'm afraid i'm in a similar boat as you Pokey, except i'm under 90 days but am oddly compliant except I have really high AHI numbers. My doctor has also asked me to do another sleep study just to get the BPAP device. Ask to speak to a supervisor if necessary. Thank you and I hope you get a good nights rest soon.
Lsparks1 go back to page 68 in my thread. SarcasticDave posted the rules for converting to Bipap. As I read them if you are still within your 90 day trial period and compliant you are NOT required to have another sleep study. I’m past 90 days and lost compliance, I think, during my 3rd month. I may be out of luck getting Medicare to pay for it but I’m gonna give it a try as it’s “medically required”.
