This is an excerpt from my forthcoming book, The 7 Day Sleep Apnea Solution: Get the sleep you need and the life you want. Please feel free to make comments and suggestions. If I select and implement your suggestions, I’ll acknowledge you in my book.
When to recheck pressure or calibrate your machine pressure?
If your machine is not working like it used to, or you’ve gained of lost significant weight, you may want to re-calibrate your pressure. It’s also a good idea to think about re-calibrating every 2-3 years, even if you’re doing well, especially if you have a straight CPAP machine. Most sleep doctors will want you to come back and undergo another in-lab CPAP titration. Some physicians will manually adjust your pressure up or down by a few notches depending on how you’re feeling, without doing another sleep study. With newer data-reporting machines, it’s easy to see whether or not you need to change your pressure. If you think that your machine is defective or not able to maintain a prescribed pressure, check with your sleep lab or DME company. They have pressure reading devices that can check your machines for you.
I would think that the cost of giving you an APAP device with full data reporting capabilities would significantly offset the need for an overnight CPAP titration study every 2-3 years. I’m sure that sleep physicians, DME vendors, and insurance companies will have widely differing views on this issue.
PAP Compliance Matters
PAP machines are generally covered by insurance carriers, with CPAP being generally offered first, and then moving up depending on the patient’s response to CPAP therapy. Most are paid for the by insurance company outright, so it’s yours to own, and sometimes it’s on a rent-to-own plan. Medicare pays for it in increments for 13 months. On month 14, it’s yours. However, beginning 2008, Medicare implemented a 3 month trial period where you have to demonstrate that you’ve used the machine at least 4 hours per night, for 70% of nights over 30 consecutive days. You also need to meet with your sleep physician and he or she has to document that you’ve have significant improvements in daytime sleepiness, observed apneas, or morning headaches. Some insurance companies also follow Medicare’s model.
If you don’t meet this criteria, you’ll lose your CPAP machine, unless you see your sleep physician who can advocate for another 60 day extension.
PAP Insurance issues
Since these devices are categorized under DME (durable medical goods) equipment, any copays, coinsurance, or deductibles will apply. Most insurances will cover CPAP for sleep apnea. Medicare usually pays 80% of what’s allowed. The remainder is either your responsibility or you may have a supplemental insurance that may pick it up. In some rare cases, some patients won’t have DME coverage. Your sleep lab or DME can find out this information for you. Or you can talk to your health benefits contact person.
Al the different supplies (PAP, humidifier, mask, tubing, headgear, etc.) are all billed separately. This is why you’ll see so many items on your insurance carrier’s explanation of benefits.
For the disposable parts, most insurances are on a 3 to 6 month schedule. Medicare is on a 3 month schedule. Your DME can tell you what your schedule is. Replacement parts for the mask (nasal pillow cushions, straps, etc) can be replaced anytime if it breaks. It’s a good idea to put this date on your calendar beforehand so you don’t forget and have to scramble to replace a broken mask. If you can have a backup mask on hand, it can save you from aggravation in the future if your current mask breaks.
Remember that all CPAP equipment and related supplies require a prescription from your physician.