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medicare coverage equipment/supplies

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FriendlyOrchidDeer6349 +0 points · over 7 years ago Original Poster

I was diagnosed with severe sleep apnea approximately 12 years ago and have used a CPAP ever since. In 2015, I retired and am now covered by medicare and a supplemental plan. Several months ago new supplies were needed and I contacted medicare. Since I had not had a sleep study within 3 years, they said I needed one. Last August I underwent the sleep study and then a titration. Results confirmed sleep apnea, though milder and a new setting of 9.New findings: Mild obstructive sleep apnea. Respiratory events were associated with significant oxygen desaturations (nadir of 89%) on room air. Although, overall apnea-hypopnea index (AHI) was in mild range, the supine AHI is in the severe range. The AHI may be underestimated due to lack of REM-supine sleep. I'm working with a supply provider who is approved by medicare. Now the provider states that medicare won't likely approve any supplies unless 2 additional conditions are met. The first is to obtain the notes from my PCP for the visit when the new study was ordered. The problem is there was no visit because I called his office and he ordered the study as I requested. It was all done via phone. And the provider states that since my AHI is in the mild range a secondary diagnosis is necessary for medicare to approve the supplies. Since I don't have either of the above, I'm stuck in limbo with no supplies. If anyone out there has experience with a similar situation your assistance would be appreciated. Thanks!

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wiredgeorge +0 points · over 7 years ago Sleep Enthusiast

I recently began relying on Medicare and have the same type coverage as you do but have not yet attempted to get supplies. My machine was "rented" prior to my going on medicare by my insurance company and after 12 months became mine. I have a TON of supplies from this period but will eventually need new supplies but not sure how to go about this process so am not able to offer advice.

Couple things that did confuse me... first your PCP should be able to make notes regarding our condition even based on the phone call since they felt it nequried a referral. Second condition of new supplies what you needed a "secondary diagnosis". What does that mean? A diagnosis of what? Are you limited to using only this one DME?

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DanM +0 points · over 7 years ago Sleep Enthusiast Support Team

Hi FriendlyOrchidDeer6349. Medicare's requirements are very specific, but your physician should be able to help you address their requirements. I encourage you to make an appointment and go into the office to see him. When I worked in a sleep clinic, it was very common for Medicare to require a copy of the clinic notes that contained specific information (documentation of excessive daytime sleepiness, other health conditions, etc.) and a copy of the sleep study. You might find this link helpful for your physician. It was published by Medicare in October 2016 and outlines the requirements for CPAP coverage. Hope this helps, and please let us know how it works out!

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