ASV Machine and Medicare coverage

This area is for CPAP Mask and CPAP Machine Related Questions used in the treatment of Sleep Apnea.


ASV Machine and Medicare coverage

Postby jerbark » Thu Dec 27, 2012 4:44 pm

My very elderly father is currently using a Bipap machine. My sister recently took a nap with him and noticed that he was snoring loudly and stopped breathing several times...so we called his sleep doc (he's been seeing her for 5+ years). The doctor told us (through his assistant on the phone) that my dad might have Central Sleep Apnea and needed another sleep study. We were told that Medicare might require more than one sleep study to get all of the information that they require, in order to approve the more expensive ASV machine, so we had 2 sleep studies (separate nights), then went to see the doc.

It turns out that the first study was just to monitor my dad with NO CPAP or BIPAP machine on. We found out that his sleep apnea is worse than it was 2 years ago - do ya think? We already knew this when we reported that his breathing with or without the BiPAP was the same (based on my sister's observations). I asked the doctor what the point was in having the first study done and he really couldn't give me an answer..

The doctor's office called and told us we needed to have the second study done (because Medicare required it). The second study showed that he does have both obstructive and central sleep apnea and that he did the best, when he was put on an ASV machine (which I've come to learn is a relatively new machine, only manufactured by Resmed i.e. not all suppliers have this machine in stock).

After the two sleep studies, we were told to come in for an office visit. At the office visit, the doc told us that UNFORTUNATELY, the Medicare guidelines RECENTLY changed and in order for Medicare to approve the ASV machine (which the sleep studies indicated would be the best for my dad), we were required to have an OFFICE visit, PRIOR to the sleep studies being ordered/performed i.e. the two sleep studies we just went through, were INVALID. The doctor said that this is a "new" requirement and that she didn't know about it...and now she wants my dad to have a THIRD study performed (interesting that we were originally told that we needed TWO studies for Medicare to approve the ASV machine and now, AFTER an "office visit", we only need ONE study for Medicare approval...).

I've called Medicare to try and get info re these "new" requirements and that has just been an exercise in frustration. Someone from their "Resolutions Dept" called me and gave me information on the coverage requirements for a CPAP/BIPAP machine, but I was told me that they couldn't give me any more information re an ASV machine...The only Medicare dept that had the information re the possible guidelines coverage of an ASV machine was the "Medicare Provider Line" (essentially their billing department) and the ONLY people who have access to this are the DOCTORS' OFFICES because they have a "special number to call and a special ID code" i.e. even MEDICARE RESOLUTIONS couldn't call this department...

Anyhow, does anyone out there know what the Medicare requirements truly are for covering/paying for and ASV machine? Have they "recently" changed, or is this doctor just lying (I think he has a financial interest in the sleep study company...).

Has anyone gotten Medicare to pay for an ASV machine?

What did you have to do before getting the approval/coverage?

Thanks!
jerbark
 
Posts: 1
Joined: Thu Dec 27, 2012 4:18 pm
Machine: Resmed
Mask: pillows
Humidifier: yes
Year Diagnosed: 2005

Re: ASV Machine and Medicare coverage

Postby Bons » Thu Dec 27, 2012 9:42 pm

In the past, medicare and insurance companies would only pay for ASV's if cpap and bipap were first proven ineffective. That should be the case for your father, as he is still having problems while on bipap.

It is not uncommon to have a new sleep study without cpap to confirm the diagnosis. If he was not titrated for ASV during the second study, then he will have to have a third one. ASV's are complicated machines with many variables,- not just inhalation and exhalation pressure, but also minimum and maximum pressure support, minimum breaths per minute, volume of breath, etc. so the only way to prescribe the proper settings is to do an overnight.

Can your doctor's office staff help fight this battle for you? Or call your local office of the aging to see if they have a medicare person who can help you figure things out.

Also, ASV's are also manufactured by Phillips Respironics. The price has dropped significantly (a couple of thousand dollars) since I got mine two years ago.
PR bipap auto sv advanced
Fisher and Paykel flexifit 431
Bons
 
Posts: 572
Joined: Fri Sep 03, 2010 1:11 pm
Location: Pennsylvania
Mask: fx for her nasal mask



  • Site Supporter

Return to CPAP Mask, Machine, & Monitoring Treatment Questions

Who is online

Users browsing this forum: No registered users and 0 guests