Supposedly, Medicare gives equal coverage for both CPAP and oral appliance therapy. However, there are reasons why the two often don’t end up getting equal coverage. It means that some people can get stuck with CPAP or have to pay out-of-pocket for oral appliances, if they’re not careful.
That’s why we’re calling our patients’ attention to the rules so that everyone can get the treatment that works best for them.
A Rule That Can Stick You with CPAP
The rule has a good foundation: Medicare wants to avoid paying for two different treatments for your sleep apnea when you only need one. To avoid paying for two treatments, though, they require that you return your CPAP machine within the initial 90-day trial period. If you don’t, then Medicare won’t cover oral appliance therapy for five years!
Now, there are some exceptions. If you have a major change in your health that makes CPAP intolerable, they may cover oral appliance therapy. But the conditions are very limited, such as a serious sinus infection or facial surgery. It has to be a medical cause. It can’t be any of the number of things that can make people not want to use CPAP, including claustrophobia, leaks, or strap problems. Medicare thinks that if you had those problems, you had to bring them up during the 90 days or just deal with them.
Get the Right Treatment for You
So how can you avoid getting stuck with CPAP? You just have to be vigilant.
If you’ve been prescribed CPAP, you will have to meet your doctor to talk about how your 90-day trial period is going. Come to that meeting prepared. If you’ve been having trouble with CPAP, tell your doctor about these problems. Tell them you intend to return it. Don’t let your doctor convince you to “try a little bit longer” because if you do, you will be stuck with it for 5 years! Besides, problems with CPAP aren’t likely to get better.
Once you’ve told your doctor about your decision, promptly return your CPAP machine and get a receipt. If you can return it to your doctor’s office, bring it with you for this visit, but make sure you get it returned as soon as possible and definitely during the 90-day period.
But you might not have to get CPAP at all. Instead, talk to your doctor about oral appliance therapy. If you have mild or moderate sleep apnea, you can get oral appliance therapy first. You don’t even have to try CPAP.
For people with severe sleep apnea, you have to try CPAP first. But you can switch to oral appliance therapy. If you’re having trouble, follow the procedure and return your CPAP machine in the 90-day window.
Having Trouble Understanding the Rules?
If you are having difficulty understanding your insurance company’s rules for sleep apnea treatment, we can help. Please call (402) 493-4175 today for an appointment at the Advanced Dental Sleep Treatment Center in Omaha.
