Medicare issues for buying CPAP headgear

by Bill Burkett
(Washington State)

I was dxed with sleep apnea, both types, 20 years ago. After CPAP use for several years, a corroborating study was conducted; confirmed CPAP couldn't handle the central part of my apnea.

Okay. Symptoms persisted of course even with CPAP. A THIRD test confirmed the CPAP was doing all it could with obstructive; central still unaddressed.

In asking for a new CPAP machine (mine was getting old and loud after over ten years nightly use) insurance said I had to have another test to confirm I needed one (!)I had insurance then so what the hell.

Test number four verified all previous results, and codified that about 50 percent of my apnea was obstructive, 50 central--no wonder I was still tired right? This particular doctor recommended a new machine computerized to respond to central events. Before he could follow up I had to move to another state, and with my insurance running out and Medicare looming, repeated my request for a new machine. a NEW set of doctors refused to send for the studies just concluded and would not prescribe for me without their own sleep study. TEST Number five!

Better hurry I said, insurance is running out and I have no idea what Medicare covers. They didn't hurry; insurance kicked back the cost of the new machine (another plain CPAP because this new doctor "didn't believe" another type of instrument could handle central apneas; in fact "didn't believe" central apneas really exist. He didn't even bother to submit billing to Medicare--his problem not mine.

But I am stuck with a new CPAP doing what the old one did (quieter at least. Now all I want is a new headgear when the present one wears out. Well guess what? Not without ANOTHER SLEEP study! This is ripping off Medicare because they want an RX scrip for a headgear, and I can't afford to pay for headgear by myself.

I can find no medical justification anywhere on Google Earth for SIX tests after FIVE have all said the same thing. Am I missing something? (Since I am retired I can sleep all I want; a sympathetic GP ordered oxygen for me to mix with my CPAP to try to prevent strokes/infarctions in the middle of the night.

So, question, as Rutger Hauer says in Blade Runner:
is a sleep study required every year for medical reasons before getting a new headgear?


Bill, you have quite a strange situation here. Although many patients - especially those with CPAP machines - have difficulties with Medicare insurance and DME, your story proves that sometimes Medicare is going too far.

I know that Medicare will not pay for any CPAP equipment or accessories without a proper evaluation of the patient. This evaluation means face to face evaluation by a doctor to asses the symptoms, or having a sleep study.

Actually, this evaluation should happen after 12 weeks, and then after 12 months to keep or increase the CPAP coverage by Medicare. You can learn more from Medical Policy Document from Medicare.

The Medicare policy for changing the CPAP mask headgear is "replacement on every 6 months", and for the mask (which is mentioned without the headgear) is 3 moths.

Now it depends how is the DME policy related to headgears and CPAP masks. The majority of DMEs respect the Medicare policy: new mask replacement every 3 months, and new CPAP headgear replacement every 6 months.

But I never hear about the necessity of getting a sleep study done before receiving CPAP accessories. The only hint could be that you moved to another place, where you have a new DME with different policies.

This is unfortunate. But you have two choices:
  • you could find another DME, and ask them if you can buy from them a CPAP headgear through Medicare.

    I read somewhere in forums that some DMEs send an entire mask and headgear every 3 month to Medicare patients, but they only bill for the headgear every 6 months though (as per Medicare code).

    In other words, the patient gets a new CPAP headgear every 3 months, but is only charged every 6 months.

    The reason for DMEs to use this method is the complications to keep separate the headgears for each CPAP mask style. Furthermore, buying in a complete setup (mask + headgear) from the manufacturer is cheaper than buying separately.

  • another alternative is to buy a headgear from ebay, where you can find much cheaper accessories for CPAP.

Telling the truth, I would like to know the exact solution to your problem. You made me curious. And I can't believe there is no doctor or another professional that can help you.

Some more interesting pages for you to check out:

I hope it helps. Don't be afraid to comment back.

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