The question in regards Medicare coverage for determination of a CPAP (Continuous Positive Airway Pressure) is pretty simple. I will summarize the steps deemed necessary by Medicare in order for you to receive this product at little or no cost to you.
First: Once it has been determined by your general physician that you may have OSA (Obstructive Sleep Apnea) which is usually linked to morning headaches, loud snoring, high blood pressure, and moodiness. He or She will send you for a sleep study. There’s a bigger word for this study but just for reading ease lets keep it simple.
The vast majority of the time there are two sleep studies performed. The first one also known as the initial study involves you sleeping without a CPAP or BIPAP. You show up in your pajamas and go to sleep, hence sleep study. During this first night they will put all kinds of crazy stuff on you to determine whether or not you’re getting a good nights rest. Once your physician’s suspicion of you having OSA is confirmed, you will then go in for your second sleep study. Same thing, show up in your PJ’S! This one though involves the use of a CPAP or BIPAP, they both do pretty much the same thing, with the exception of the BIPAP which has two different pressures, no biggie though, and both just blow air. Ok, so the sleep lab and your physician has both determined that you need a CPAP or BIPAP, but who’s going to pay for this? Medicare and Medicaid both allow payment(s) to be made on a CPAP or BIPAP if all of the above criteria have been met. The most important fact to remember is that Medicare will only pay if you are using it!
Initially there’s nothing that Medicare has to have on file for you in order for them to provide coverage for your CPAP or BIPAP. It’s actually the responsibility of the Medical Equipment Company who received the prescription from your doctor to make sure everything is accurate and correct. All billing with Medicare is done in “good-faith” meaning Medicare will take the company’s word for it. However, most medical equipment companies are usually very accurate in what they do, or they would not receive payment from Medicare for providing you the CPAP, which would obviously be harmful to the sheer existence of the company if this was to happen over and over.
Once you have received the machine it does become your responsibility. Medicare a few times per year wants to see that you are in- fact wearing your machine. They do what the professionals call a compliance report. It’s a crazy math formula to see if you are wearing your machine 70% of the time or not. If you are not, Medicare will not pay any more money to the company who provided you with machine, and you know what’s next. Yes, the company will come and take the machine and be on their way. Medicare will make payments for 12-15 months. After this rental period has expired the CPAP or BIPAP becomes your property.
Another thing to remember is all of the different items that will with your CPAP. Tubing, filters, headgear, and your mask are all considered disposable items, and Medicare will pay for each item ever few months or so. Be sure to stock up! Also a bunch of air going in your nose or mouth will cause major irritation. For this reason CPAP’S or BIPAPS usually come with a heated humidifier, and the last time I checked almost all humidifiers come attached to the CPAP machine itself.
Ok, I have tried to simplify the process involved in regards to the how’s and why’s of Medicare coverage and your CPAP or BIPAP machine. One thing I did fail to mention is why someone needs a CPAP or BIPAP. In short though, it has to due with the extra fatty skin inside your throat that simply blocks your breathing, which drops your oxygen level! That’s why you hear really loud snoring with someone who has OSA, it’s similar to a person making sounds with their lips when they have their lips squeezed together, same philosophy. CPAP’S push back this flap of skin or tissue that has occluded or blocked your airway, allowing good ventilation, thus allowing for a better nights sleep. So, keep it simple, where your machine, and remember this is not rocket science, and you’ll be fine. If all of the above in your situation are true then you should really have no problem getting Medicare to pay for your machine, 80% that is!