Beneficiaries Entering Medicare
For beneficiaries who received a PAP device prior to enrollment in fee for service (FFS) Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the coverage requirements must be met:
1. Sleep Test: There must be documentation that the beneficary had a sleep test prior to FFS Medicare enrollment that meets the Medicare AHI/RDI coverage criteria in effect at the time the benefciary seeks Mediare coverage of a replacement PAP device and/or accessories. And,
2. Clinical Evaluation-Following enrollment in FFS Medicare, the beneficary must have a face to face evaluation by their treating physician who documents in the beneficiaries medical record that:
A. The beneficary has a diagosis of obstructive sleep apnea, and
B. The beneficary continues to use the PAP devide.
If either criteria 1 or 2 above are not met, the claim will be denied as not medically necessary. In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.
Case Example:
I was diagnosed with central sleep apnea durng a sleep study conducted in 2003 six years prior to joining Medicare. When I went to get a mask replacement, I was told about the new Medicare described above. I won’t need a new sleep study if records can be submitted to the durable equipment provider, but I did need to make an appointmentn with my doctor to meet the criteria described under #2 above.
There has been a great deal of abuse in the durable medical equipment costs with Mediare and has contributed to the annual $60 + billion in excess abuse with fly by night companies many in Florida who falsefy their records and bill Medicare for sleep apnea equipment with fictional beneficaries and pocket the money, so this type of requirement is necessay to at least get documentation from a doctor that there is a need for the patient to use this equipment.
Coach
