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RX (PRESCRIPTION) FORM SLEEP APNEA ASSESSMENT                                      
REQUIRED TO PURCHASE                           
CERTAIN TYPES OF  EQUIPMENT                      
FIND OUT IF YOU'RE AT RISK                                                                                       
  

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CPAP AND SLEEP MEDICINE FAQ & MEDICARE CPAP/BILEVEL COMPLIANCE REQUIREMENTS

 

1. What is CPAP?

CPAP stands for "Continuous Positive Airway Pressure". It is the most widely accepted form of treatment for Obstructive Sleep Apnea, a condition that occurs during sleep, resulting in the partial or complete blockage of the airway by soft tissues in the throat. CPAP is the application of a nasal mask or interface that allows the pressure to be delivered to your airway.

 

2. What is Bilevel?

Some patients have difficulty adjusting to, or tolerating CPAP because they can't exhale against the positive pressure required to correct their condition. These patients are indicated for "Bilevel" therapy, in which separate inspiratory and expiratory pressures are delivered, allowing a lower and more tolerable pressure upon exhalation.

 

3. Does insurance cover the cost of CPAP and Bilevel equipment?

Most insurance companies, including Medicare, cover the costs of the equipment necessary to treat sleep apnea. Medicare and private insurance companies have specific guidelines for the provision and reimbursement of the equipment and supplies. All cases are unique. Keep in mind individual insurance plans are subject to deductibles and co-pays.

 

4. Do I need a prescription for CPAP / Bilevel, and/or supplies?

Absolutely! A physician must order your therapy. Masks and headgear are "legend" items and are regulated by the Department of Health Services. A physician must prescribe all legend items. Any items to be considered for re-imbursement through your insurance requires a prescription. You can buy filters and tubing without a prescription.

 

5. What are the symptoms of Obstructive Sleep Apnea and how do I find out if I have the condition?

The most common symptoms of Obstructive Sleep Apnea include snoring, daytime fatigue, poor cognitive function, in-ability to remain mentally focused, agitation, insomnia, and depression to name a few. You should see a doctor as soon as possible to have an overnight sleep test scheduled and performed. This sleep study will document if you have Obstructive Sleep Apnea.

 

6. Who can use CPAP or Bilevel?

Most patients can use CPAP / Bilevel therapy, but there are areas of concern. Age is not an issue. Some patients have poor tolerance to a device on their head or face with straps, etc. when they are sleeping, and this leads to non-compliance. Patients with range-of-motion disabilities may have difficulty putting the interface on properly and should have a caregiver available to help them.

 

7. Can I be tested at home?

It is possible to be tested at home but Medicare will not pay for it. Private insurance will sometimes authorize a home study but the level of testing is not as good as a sleep laboratory for several reasons. Some of those reasons are that most home studies are not attended by a sleep technologist, and those studies cannot isolate additional problems that may occur during sleep that can mimic the same symptoms as Obstructive Sleep Apnea. Limb movements, hypoventilation, and sleep staging are generally invisible during a home sleep study.

 

8. How do I get my equipment once I am diagnosed?

Your sleep study, report, and recommendations are sent to your physician from the sleep lab. Your doctor will then write a prescription for the appropriate therapy. This can then be taken to the CPAP Provider of your choice (i.e. AirCare Home Medical), or one that is contracted with your insurance company. Your sleep test is then evaluated for qualifying based on the requirements of your insurance carrier, and once qualified, you will be contacted by the CPAP Provider to schedule an appointment.

 

9. How long does it take for the therapy to work?

For some patients, as soon as overnight. Obstructive Sleep Apnea interrupts and fragments consolidated and restorative sleep. CPAP and Bilevel therapies correct this problem by maintaining a patent airway, eliminating sleep fragmentation due to repeated awakenings during the night to breathe.

 

10. What surgical options are available and do they work?

There are several surgical options available and you should speak with your physician about them. In general, surgical procedures (except in rare cases) have limited success. CPAP and Bilevel therapies work if you use it.

 

MEDICARE CPAP/BILEVEL COMPLIANCE REQUIREMENTS

Medicare has specific rules to follow for their beneficiaries when CPAP/BiLevel equipment is ordered. After an initial period of time, Medicare wants to make sure you are compliant with the equipment before they continue to pay for it.

 

A. After you have been set up on a CPAP/BiLevel, you must make an appointment with the physician that ordered your CPAP/BiLevel equipment between the 61st and 90th day from the date your equipment was set up.

 

B. We will have to get information from your CPAP/BiLevel equipment so that we can provide your physician with a report outlining your usage of the machine. We will then fax that report to your physician prior to your follow up appointment with the doctor. This will be discussed with you during your set up.

 

C. After that appointment, you physician will need to provide copies of chart notes indicating you are using the equipment for a minimum of 4 hours each night for at least 30 days, and that the CPAP/BiLevel equipment is providing improvement to your condition.

 

If the above Medicare requirements are not met, Medicare considers the equipment to be not medically necessary. Should you wish to continue to use your CPAP or Bi-level device you will be financially responsible.