Dealing with a DME
The acronym DME stands for "Durable Medical Equipment". "DME" is also loosely used to refer to a company that sells medical equipment or to the individual representative of an equipment supplier; it is in this context that we use the term "DME" in this article.
- 1 Advice for brand-new patients
- 2 On-Line Purchase
- 3 Handling the DME
- 4 User DME Interactions
- 5 Insurance and/or Medicare and DME (for CPAP)
- 6 Medicare Advantage plans
- 7 Medicaid
- 8 Obtaining disposable supplies
- 9 Obtaining a replacement machine
- 10 Changing DME Providers
- 11 DME Checklist
- 12 DME or Sleep Specialist Says I Need a New Sleep Test
Advice for brand-new patients
Documentation is important.
- Get a copy of your Sleep Study/Studies.
- Get a copy of your Prescription
Within these basic CPAP machines are many models with different capabilities. The machine of choice is an Auto CPAP. The most recommended Auto CPAP recommended on the Apnea Forums is the ResMed AirSense 10 AutoSet (best choice) (E0601) with heated hose (Fixed CPAP, Auto CPAP) (or the for her version) Another good machine is Philips Respironics DreamStation Auto CPAP Machine (DSX500x11) (Not all DreamStation Models, Check SN on the bottom, bricks look the same) (Fixed CPAP, Auto CPAP) (best choice)
Why you want Auto CPAP.
- It is a very versatile machine
- It can be used in either Fixed CPAP or Auto CPAP modes
- It provides Compliance Data
- It may be used for home, or self-titration
- It provides full efficacy data (detailed data down to breath by breath info if necessary) that can be read and evaluated by doctors office to modify treatment or yourself for “info. This data can either eliminate the need for an additional sleep study or highlight the need for an additional study.
- You will be using this machine every night for about 5 years, It is likely that your treatment will change over this time. The auto function will adjust pressure as required to meet changing circumstances (even mundane things like sleeping on your back or side)
- The "For Her" includes an extra algorithm which provides gentler pressure changes and is (apparently) more attuned to the patterns of flow-limitations experienced by women
- The Resmed machines typically respond much faster to precursors, killing many apneas before they get a chance to develop
- These machines are supported by OSCAR software to allow you to monitor and optimize your own treatment.
Read this APAP Prescription
Most users do not need a BiPAP/BiLevel or an ASV machine. Nearly everyone is prescribed CPAP even if they may have more complex problems. BiPAP/BiLevel/VPAP or ASV machines are important for more complex problems. Individuals that need pressure support (PS is the difference between the inhale and exhale pressure) to assist inspiratory effort to overcome airway resistance, flow limitation, pulmonary problems like COPD or that need to increase tidal volume, must be aware that the medical system frequently fails (by design) to prescribe the best treatment. Bilevel pressure and backup rates are needed to treat central and complex apnea and Cheyne-Stokes Respiration (CSR).
If you do not have insurance, Medicare, have a high deductible, etc. to help you pay for your machine or supplies, this is the way to go. Options include various on-line DME suppliers, Amazon, craigslist, other private purchases. Try to use known suppliers.
CPAP Supplier List is a list of on-line DME suppliers generated by Forum Advisory Members. Read the cautions in this link. Craigslist is a private sale, use all due cautions.
The used (craigslist) market is available without a prescription, but the choices and prices are all over the place.
It is highly recommended to post to the Apnea Board Forum for current information on on-line sales.
In the US a prescription for CPAP has been a requirement since the beginning of CPAP use. (CPAP machines are an FDA regulated class II medical device in the U.S., which requires a prescription). In recent years, FDA regulations have also included CPAP masks as an "integral" part of a CPAP and therefore also classified as part of a class II medical device as well (prescription required for those as well). That said it is possible to purchase without a prescription.
Handling the DME
The DME gets paid the same for a (ResMed AirSense 10 AutoSet) state of the art Auto CPAP as it does for a much cheaper, potentially older model, fixed CPAP that has no data capability (affectionately called a brick). The “Brick” will be more profitable for them, and much less useful for you. YOU are the customer. YOU have the right to choose your DME. Do not be afraid to go elsewhere to get what you want, and let your DME know that. Know what model machine you want, not just the brand. For example below are two current ResMed models. If your Rx is for a "CPAP" with Humidifier, in the ResMed line you could get either of these.
AirStart™ 10 Auto CPAP with HumidAir™ Heated Humidifier (you do NOT want this machine) $400 retail May 2017
- Compliance Data to SD Card
- NO detailed efficacy data, which is used to identify alterations and tweaking of your treatment.
- Operation Modes
- Fixed CPAP only
AirSense™ 10 AutoSet CPAP Machine with HumidAir™ Heated Humidifier $883 retail May 2017
- Compliance Data to SD Card
- Advanced Data
- Operation Modes
- Fixed CPAP
- Detailed breath by breath data indicating how you are responding to all breathing events thru the night
The DME gets paid, from your insurance, the same for both of these devices, which do they make more profit from? Which is more useful to you?
How to make it easier
Your leverage: You have a choice of which DME you use, you can always use another DME, if you do so the original DME makes nothing. They frequently try to make you think you have no choice.
Think of the DME as a grocery store. If the grocery store doesn't want to sell you what you want to buy, what do you do? If the employees of the grocery store are rude or obnoxious, what do you do? I go to a different grocery store.
If your prescription states a specific model and states dispense as written (DAW), the DME has no choice. Work with your Doctor to do this. Know the reasons that you want an Auto CPAP. Most doctors wand to prescribe a fixed pressure. Point out that an Auto CPAP will operate in Fixed CPAP mode BUT has the flexibility to switch to Auto CPAP if needed.
You want to get a New machine. You will be using it for about 5 years and usage hours (not therapy hours) should be very low. (DME’s have been known to provide “used” machines as new.) So learn how to get to and read the usage hours for your machine.
Call the DME before you show up and let them know what you expect to get, specifically an AirSense™ 10 AutoSet CPAP Machine with HumidAir™ Heated Humidifier and Heated Hose. Let them know that you are an INFORMED customer. When you jump into the clinician menu to check the total hours they will be surprised.
Most "customers", especially new ones, at a DME are not knowledgeable about the CPAP equipment and the treatment of apnea. Would you buy a car with an instrument panel that didn't work? Didn't think so. Why would you buy a CPAP machine that only provides Run hours? Let's keep with the car analogy for a bit. You just got married and you bought a sweet two seater. You decide to start your family, you need a bigger car. Your family continues to grow and you get an even bigger car. Wouldn't it be great if your car could change according to your needs? Well an Auto CPAP can do just that.
Masks are extremely important. So much so that they are at times called “Interfaces” because they interface between the machine and your face. Masks are typically the hardest to get right. That is because your face is unique. Visits to the DME are opportunities to try masks. Take advantage of these visits. Oh and read the Mask Primer.
User DME Interactions
One users Path to machine
Here's my thumbnail sketch of how I got my latest CPAP/ASV blower:
- I called my health insurance Customer Service, we discussed which DME's were in-net nearby, I noted names/addresses/phone #
- I called above noted DME's to decide which I wanted to deal with, determined mostly by geographic location and products carried, AND by reputation
- After the ASV version of PSG, I called the pulmonary docs office to tell them which DME to use for the ASV script
- Called DME, doc, and insurance MULTIPLE times until my script was filled with newly prescribed ASV
- Waited 24 hours and repeat step 4 then step 5 over for a few weeks
BTW step 5 has NO sarcastic intent; this is really what happened. I didn't sit very long while waiting on these 3 amigos to do anything. At least one of the 3 heard from me every day until I knew the machine was to placed in my hands on a certain date and time.
I would call your doctor's office and let them know that the DME they've referred you to is interfering with your ability to get treatment for your affliction. Make it a medical complaint rather than a service complaint because the staff is trained to deal with medical complaints in a much more structured manner. That is, you are more likely to get results that way. One call from the doctor's office to that DME may be enough to get them in gear.
For example, when I told my doctor that I needed my machine because a lack of sleep was having a serious effect on the quality of my life he had his nurse issue a "stat" order. The DME called me a couple of hours later and delivered a machine to my home that afternoon.
You can do a couple of things to make your experience better.
- Read the wiki on this site and know what you need to get (ResMed AirSense 10 AutoSet, mask of choice, tubing, filters etc.)
- Go ahead and call your insurance and get a DME referral. They will give you a minimum of three as anything else would be kickback territory.
- Then call the doctor and ask his assistant who they deal with. They will also give you a couple of choices.
- Then get the list and call them all. Ask about masks, exchanges, fittings, what machines they dispense, which doctors they work with everything you can think of.
- Go down the list... It won't take you long. If their customer service is crap on the phone you can rule out.
- One caveat is most of the equipment is usually dispensed by a respiratory therapist and DME sell a bunch of stuff usually.
- You'll be getting follow-ups with the doctor so getting your script is easy enough. I'm sure they can easily fax, email or send it you.
- It's best to have a DME closer. You might go through 3-5 masks in the limited 30 day window they give you.
- Best not to do that online honestly unless your deductible is huge. Most online places are selling things for just a bit more than Medicare reimbursement.
- The CPAP machine is roughly $800 which is just a bit more than Medicare pays them however your DME will "bill" your insurance company 1200 or more so a 20% deductible "could" be more than the machine costs.
- An unscrupulous DME will often try to get you set up supplies which come out of pocket that are not needed etc. Special CPAP wipes, etc.
- My DME works directly with the doctor and was super easy to deal with. Gave me exactly what the doctor ordered. They didn't do much to help choose masks but they did show me how to use the machine and spent 20 minutes with me. They went over the manual on cleaning.
- It seems overwhelming but it's really going to go smoothly.
Today was the start of my therapy so drove 35 miles to my new DME to get my new ResMed AirSence 10 AutoSet.
There were several new boxes piled on the floor but he pulled one off a shelf that was in a travel bag. I checked the power cord and machine and it looked used. I asked him 3 times if the machine was new - he said yes. I asked him if he checked the clinical menu “about” for time and he pretended to not know what that was.
I needed a good mask fit so went through process testing under pressure with me ending up with ResMed P10 nasal pillow.
Went home plugged in the machine and went into the clinical menu and bingo machine had 1,359 hours on it. I immediately called and he said, “it should have been new, must have been a mix up with the machine in the backroom, he will bring me a new one.”
Hell with that I drove back and traded after verifying I had a brand new machine.
It was no mistake - he lied and tried to give me a used machine with lots of hours on it.
Thanks to this forum and help on my first post that gave me the knowledge to be educated and not allow fraudulent DME to cheat me & Medicare.
Thank you and warning to all new users.
It happened to me too. I remember picking up my machine and they said it was new right out of the box. I didn’t see a box. Sad But anyway, I used the machine for 6 weeks before finding this forum. That’s when I discovered how dishonest some DME’s can be.
Out of curiosity, I looked at my machine hours and saw that it had over 900 blower hours on it. Of course, they had erased the previous user hours. The machine/blower hours cannot be reset.
I called and told them what I found and that I would be in the next day for a new machine. They argued with me that it was new, so I explained that I knew the difference between user hours and machine hours. Dead silence on the phone. When I got there, they had the “new” machine ready. I asked if I could see the machines/blower hours and the tech seemed to struggle with how to find it. So I showed him. Sad
It really is a shame that some, not all DME’s are dishonest.
Bottom line....ask to see the units blower hours before accepting it.
Oh, and never accept their word that they will check your insurance coverage for you....do it yourself!
Insurance and/or Medicare and DME (for CPAP)
Make sure the provider is in-network for your insurance company, or agrees to accept assignment as a medicare provider. Most insurance companies will provide a list of in-network providers or maintain a list on their website. If you use health insurance to obtain equipment and supplies, you should start by choosing a provider that is in-network. For Medicare, go to this site (official Medicare Site). Medicare Supplier Directory Enter your Zip Code then select "Continuous Positive Airway Pressure (CPAP) Devices" The results will be a list of DMEs that you must use for Medicare coverage. Note: This is not applicable to those who have Medicare Advantage plans, who must check with the insurance company who provides your Advantage plan. Also be aware that a participating provider may not be one that accepts assignment. Assignment means the provider accepts Medicare payment, plus any deductibles, as payment in full, and you cannot be charged unexpected surcharges beyond your coverage. Lower costs with assignment
Medicare CPAP Qualifications CPAP Qualifications (E0601) Patient must meet all the following criteria to qualify for an E0601 device (CPAP)
Patient has had a face-to-face clinical evaluation by treating physician prior to sleep test.
Patient has had a sleep test which meets Medicare Requirements that meets either of the following criteria:
- AHI/RDI3 is ≥ 15 events per hour with a minimum of 30 events; or,
- AHI/RDI is ≥ 5 and ≤ 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or history of stroke.
- Diagnosed with OSA (ICD-9 code of 327.23)
- Patient and/or caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment.
Medicare usually pays rent to the DME for 13 months, and after that time, you own the machine.
And then there is compliance, min of 4 hrs use for 21 of 30 days, easy since you are going to use this every day for a number of years.
Medicare Advantage plans
You need to check with the insurance company who provides your coverage. For example, if you check the Medicare site, your only choice may be Apria. My Addvantage plan provides coverage from four different DMEs. Lincare was chosen, which could not be used with conventional Medicare.
Details to come later
Obtaining disposable supplies
For apnea patients, disposable supplies include but may not be limited to; masks, mask interfaces (cushions), headgear, chin straps, filters, hoses, and humidifier chambers. For patients obtaining disposable supplies through insurance (personal, employer provided, Medicare, Medicare Supplement, Medicare Advantage etc.) guidelines for replacement intervals vary. For patients that self pay, practically any provider will be happy to sell whatever is needed. Some will ask for a prescription, some will not.
For the patient obtaining disposable supplies through insurance, some DMEs will remind you when you become eligible for supplies and others will make no effort to remind their patients making it necessary for the patient to initiate the process. Recent changes appear to make it necessary for the DME to obtain a new prescription for each new supply order. This situation emphasizes the necessity of teamwork all around. More than ever the patient must be actively informed and at times involved in the process. If the doctor and the nurse are not on the same page as the DME the patient may need to add some diplomacy to the mix. It's not unusual for the doctor's nurse to be the key player.
Medicare prohibits auto fulfillment of replacement supplies. You MUST initiate the ordering of all replacement supplies with Medicare. How often can you replace disposable supplies? Look at the Medicare Replacement Schedule.
Note: Many non-Medicare Insurance plans follow the Medicare schedule, but call and ask to be sure.
When you are first starting out, and as long as you have decent insurance coverage, it’s a good idea to follow the replacement schedule and build a small stockpile of supplies. Most of us would rather not skip a day of therapy for any reason.
What do you need
- Mask (there is NO therapy without a mask)
- Cushions (tend to get soft and cause a leak)
- Pillows (tend to get soft and cause a leak)
- Headgear (gets stretched)
- Hose (can get a hole in it (dog/cat bite mark))
- Filters (replace monthly)
- Humidifier Chamber (An integral part of many CPAPs, if broken - NO therapy)
Many of these supplies will last longer than the replacement schedule offered by insurance.
Obtaining a replacement machine
Helping patients replace their current CPAP machines (2014) Less than five years The replacement of an item before its five-year lifetime expires can only be done if the item is lost, is irreparably damaged, or the patient’s medical condition changes and the item no longer satisfies the medical needs of the patient.
- Loss or irreparable damage: – Irreparable damage is considered damage caused by a specific accident or natural disaster. – A physician’s order is needed to reaffirm the medical necessity of the item.
- If a PAP machine is replaced during the RUL because of loss, theft or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test or trial period.
- The supplier must replace the equipment free of charge if it does not last the full five-year period (ie, is no longer serviceable or needs substantial repairs). If it is determined that the item is unable to last for the entire five-year RUL based upon accumulated repair costs (those repair costs exceeding 60% of the cost to replace), the supplier must replace the equipment with properly working equipment at no charge. Replacement equipment does not need to be new.
If you have a chronic condition and will need DME for a long period of time, it important to learn about Medicare’s rules for replacing your equipment. Replacement means substituting one item for an identical or nearly identical item. For example, Medicare will pay for you to switch from one manual wheelchair to another, but will not pay for you to upgrade to an electric wheelchair or a motorized scooter. Medicare will pay to replace equipment that you rent or own at any time if it is lost, stolen, or damaged beyond repair in an accident or a natural disaster. Medicare should cover a new piece of equipment with proof of the damage or theft. If your equipment is worn out, Medicare will only replace it if you have had the item in your possession for its whole lifetime. An item’s lifetime depends on the type of equipment. An item’s lifetime is never less than five years from the date that you began using the equipment in the context of DME replacement. Note that this five-year time frame differs from the three-year minimum lifetime requirement that most medical equipment and items must meet in order to fall under Medicare’s definition of DME. The item must also be so worn down from day-to-day use that it can no longer be fixed. Keep in mind that Medicare will repair worn out equipment up to the cost of replacement before the end of its lifetime. Medicare will only cover replacement equipment if your doctor writes you a new order or prescription with an explanation of the medical need. If you are affected by the competitive bidding demonstration, you must use a contract supplier to replace your equipment. If you are not affected by the competitive bidding demonstration, you can use any Medicare-approved supplier to replace your equipment. However, you will pay the least if you use suppliers who accept assignment.
If you need DME, your equipment may need regular maintenance and repairs from your supplier. Repairs by a supplier involve fixing equipment that is worn or damaged. Maintenance means checking, cleaning and servicing your equipment. If possible, you are expected to do regular maintenance yourself using the owner’s manual. However, a supplier should do maintenance if it is more complicated and requires a professional. Medicare coverage of repairs and maintenance that is more specialized depends on whether the supplier owns the equipment or you do. If you need oxygen equipment, Medicare pays for repairs and maintenance differently. As long as you are paying a monthly rental fee for your equipment, your supplier must perform all needed repairs and maintenance that require the work of a professional. The supplier cannot charge you for this work. On the other hand, Medicare will pay a separate amount to the supplier for repairs and maintenance if you buy your equipment or if you now own your equipment after first renting it. The repairs and maintenance must require a professional and must not be covered by warranty. Medicare will pay 80% of the Medicare approved amount and you will be responsible for the 20% balance. You can save money by going to a supplier who takes assignment. If you live in a competitive bidding area and you own equipment that is on the list of items you must get from a contract supplier, it is best to get repairs done by contract suppliers. Although Medicare will cover maintenance (and replacement parts needed for the repair) from any Medicare-recognized supplier, contract suppliers must accept assignment for the repair.
Changing DME Providers
Changing DME providers is necessary for a number of reasons. If a DME ceases business operations, a patient moves out of a DME’s service area, the patient may be dissatisfied with a DME or a combination of these factors, then a patient will have to select a new DME. A patient may have options to select DME providers. Limiting factors in DME selection are Medicare competitive markets and insurance network coverage.
When you wish to change DME providers, it is important to remember that the DME considers you a patient in their care. The DME, like a doctor, keeps records of your healthcare. In order to change DME providers there is a transaction that must occur between your current DME and the DME that you seek to provide your healthcare needs.
To facilitate the transfer of your CPAP related needs, you will need some medical records. The first medical record is your prescription. Although your current DME will have your prescription on file, it is recommended to obtain a copy from your prescribing doctor and deliver that prescription to the new DME.
Secondly, if available, a copy of your sleep study will be requested by the new DME. Again, a copy of your sleep study should be on file with your current DME, since this too is a medical record, your prescribing doctor must make available a copy to you.
Third, a release of medical information document must be on file with both the current DME and the new DME. This release of information document facilitates the legal transfer of information from your current DME to your new DME. You will sign a copy at the current DME and new DME. Usually you sign this document when you complete new patient intake for any medical services you receive and the document is specific to the medical provider.
Lastly, your current insurance documentation is required for transfer. The new DME will request this from you as a potential new patient.
Having a valid prescription, a copy of your sleep study, a signed release of medical information document, and your current insurance will allow your new DME to begin the request process. Since you are considered a patient with your current DME, they have to release you from their care, much like being released from a hospital.
Once your current DME releases you from their care and insurance has given their approval, your new DME will setup an appointment to do a new patient intake. This intake process is performed anytime you receive medical care by a service provider that has never seen you as a patient before. A medical history questionnaire, personal information questionnaire, current medical needs questionnaire, vital statistics questionnaire and any other information needed to care for you as a medical patient will be obtained.
When changing DME providers, if you currently own your machine, the new DME will ask for you to bring your machine into their office when they schedule an appointment for you to begin receiving supplies. Assuming that insurance is covering your supplies, the DME will record the serial number from your machine and modem (if equipped), and collect your sleep data from your machine. This is for compliance monitoring. The DME will record the supply types and sizes you require (mask type and size, hose type, filters…) and according to your insurance policy, the DME will create your supply schedule.
It is common practice that an insurance company will rent the machine you are provided by your DME. During the rental period your DME is responsible for the collection of compliance records and reporting your usage statistics. If you fail to report compliance or do not meet minimum usage for compliance, your insurance may stop payment to your DME and the DME will stop issuing supplies. If the machine is still in the rental period, the DME will require you to return your machine.
The typical rental period will be 10 consecutive months. After the rental period and you have met minimum compliance requirements, the machine will become your property. The contract is similar to a “rent to own” contract with you being the consumer. If you change DME providers during your rental period, the insurance company reserves the right to deny the issue of a new machine. Therefore, it is recommended that you maintain your DME provider during the entirety of your rental period. After the rental period has been fulfilled and you own your machine, selecting a new DME is, in essence, only selecting who will fulfill your supply needs.
Complete before DME visit
- Read “New to Apnea? Helpful tips to ensure success”
- What Machine model do I want?
- ResMed AirSense 10 AutoSet (or “AutoSet for her” model)
- Philips Respironics DreamStation Auto CPAP Machine (DSX500x11 on bottom of machine)
- Go to the CPAP Manuals Page to get instructions (or a manual) that tells you how to get into the "Setup", "Clinician", or "Provider" Mode on your make & model of CPAP. (you want to know before you pickup your machine)
- Let your doctor know what machine you want. Ask your doctor to write a prescription for the machine you want.
- Call DME before you arrive to pick up your machine. Let them know what you are expecting.
- What Model are you planning to deliver to me?
- I want to try several masks for fitting, is that ok?
Complete at DME visit
- Questions to ask
- What is the DME Mask Policy?
- How do I get supplies? (masks, cushions, filters, hoses, etc.)
- How do I perform the mask leak test.
- Verify Machine Model received
- ResMed AirSense 10 AutoSet (or “AutoSet for her” model)
- Philips Respironics DreamStation Auto CPAP Machine (DSX500x11 on bottom of machine)
- Verify Total Run Hours (should be 0 (typically) to a small fraction of 1 hr (unusual) for a new machine).
- Based on info gathered from the CPAP Manuals Page above enter the "Setup", "Clinician", or "Provider" Mode on your make & model of CPAP.
- Once in "Setup", "Clinician", or "Provider" Mode, follow the instructions below to find the total run hours on your CPAP.
- How to check run hours on ResMed AirSense 10 AutoSet (Best Choice), AutoSet for Her (Best Choice), Elite, or CPAP
- Enter Settings menu / scroll down to About / View Run Hours [How-To Enter Resmed Setup Menu]
- How to check run hours on Philips Respironics DreamStation CPAP, DreamStation CPAP Pro, DreamStation Auto CPAP (Best Choice), DreamStation BiPAP Pro, DreamStation Auto BiPAP
- Enter the Info Screen / Device Hours [How-To Enter Dreamstation Setup Menu]
- Mask Trials
- Mask fitting and Trials!!! (under pressure on your machine (read Mask Primer)) This is an opportunity to try masks that you haven't purchased.
- Pillow mask(s) tried (note model(s) and results)
- Nasal mask(s) tried (note model(s) and results)
- Full Face mask(s) tried (note model(s) and results)
- Mask fitting and Trials!!! (under pressure on your machine (read Mask Primer)) This is an opportunity to try masks that you haven't purchased.
DME or Sleep Specialist Says I Need a New Sleep Test
A DME has no authorization to diagnose, prescribe or otherwise perform any medical function such as referral to sleep tests. The role of the DME is limited to filling a doctor's prescription and coordinating any insurance or Medicare approval, denial and reimbursement activity. Many DME providers also have Respiratory Therapists on staff that setup devices in accordance with prescribed pressure, assist patients with fitting masks, solving therapy problems and tracking usage compliance. The DME is not authorized to change machine settings without a doctor's order, and cannot refer a patient to a sleep test. They can inform a patient or their doctor that information needed to file a claim may be missing or insufficient. It is common for a DME representative to tell a patient they need a new sleep test, however if a valid sleep test has been performed at anytime in the past that meets the requirements of the insurer, and a treating physician has continued to issue a prescription for devices and equipment based on that history, it is not the role of the DME to do anything but submit a claim containing that information to the insurer.
Sleep Specialists or Doctors serve singular function specified by Medicare/CMS requirement; to sign off on a sleep study ordered by a treating physician, and used to document a diagnosis of obstructive sleep apnea. There is no requirement that a treating physician be a board certified sleep specialist. Many sleep specialists attempt to convert the subjects of sleep tests to routine care and recurring appointments. The economic incentive for a specialist to have an ongoing physician-patient relationship is obvious; however there is no requirement to see a specialist once the test is complete. The treating physician can be the same doctor a patient sees for annual exams and routine health care. It is advisable that the patient request their treating physician to assume responsibility for their ongoing PAP care and prescriptions. This will generally require routine discussion of your CPAP therapy and informing your DME of the name, address and fax for your treating physician. This arrangement saves the cost of routine vists to a sleep specialist and removes the economic incentives to perform recurring, unnecessary clinical sleep tests.
There is no mandate for re-testing when a replacement machine is acquired and the patient has been under the care of a physician, regularly discussed their CPAP therapy and indicated it is beneficial. The choice of a device to treat apnea is between the doctor and his patient and can be supported by a titration if the doctor deems it necessary, however; titration exams are never a requirement to obtain a PAP device. Medicare rules are typical. A patient qualifies for CPAP after an in-person clinical evaluation and a positive sleep test using PSG or type II, III or IV home sleep test. While the criteria for a positive sleep test is defined as greater than or equal to 15 events per hour, or 5 or more 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. CMS Medicare Requirements for CPAP
Once that examination and testing has been satisfied, there is no requirement for a patient to be re-tested, including when obtaining a replacement CPAP. Patients entering Medicare that have been tested before obtaining Medicare coverage will continue to qualify for supplies and equipment provided they have previously met the diagnostic criteria, and have continued to be under the care of a treating physician and demonstrate continued benefits of the use of CPAP. Patients can be considered for bilevel therapy if the treating physician (your doctor) makes the determinations described on this Medicare Policy summary by Resmed:Medicare Policy on CPAP and Bilevel
Surround yourselves with a supportive medical team. Stay away from sleep specialists and clinics and DMEs who give you false information that you need more tests. Keep your original sleep tests and records and don't let anyone tell you to take another test.
The key to a replacement machine is a treating physician documented that both of the following issues were addressed prior to changing a patient from an E0601 to an E0470 device due to ineffective therapy:
- a. An appropriate interface has been properly fitted and the beneficiary is using it without difficulty. The properly fitted interface will be used with the E0470 device; and
- b. The current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy, and lower pressure settings of the E0601 were tried but failed to:
- 1. Adequately control the symptoms of OSA; or
- 2. Improve sleep quality; or
- 3. Reduce the AHI/RDI to acceptable levels.