Common Reasons To Get A New CPAP Machine
There are several typical scenarios where CPAP users often consult with me to get a new CPAP machine:1. Outdated technology
- The original iteration of positive airway pressure (PAP) for the treatment of obstructive sleep apnea was the fixed-pressure CPAP machine. This machine could only be set to one consistent pressure setting. Technology has exploded since then with the introduction of auto-titrating CPAP machines (commonly referred to as APAP or Auto-CPAP), as well as more advanced forms of PAP such as BPAP, BPAP S/T, and ASV. Auto-titrating technology has been revolutionary to the field and engendered more comfort, better efficacy, and a lower overall cost as it has reduced the number of titration sleep studies that are needed.
- Just like what’s happened to computers since the 1970s, CPAP machines have shrunk in size and are a lot more portable.
- In addition to the movement toward smaller footprints in “regular” CPAP machines, there are now a number of “travel” or portable CPAP machines that are tiny. Literally, you can hold them in the palm of your hand.
3. "My machine seems like it’s dying."
- Funny noises: I often get requests for a new CPAP machine from patients who are making a preemptive strike when they start to hear funky noises emanating from their machine. These folks dread the possibility of going for a night without their CPAP.
- "The pressure doesn’t seem as high as it used to," or, "I don’t feel as good upon awakening or during the day as when I first got the machine." As machines age, their ability to maintain their set pressure can drop. Manometers can tell you if your machine is pumping out the pressure that you need. If you don't have one, and notice that you don't seem to be responding to therapy as well as you used to, it might be time to invest in a new CPAP machine.
- Common reasons to get a second machine are frequent travel, having a second home, and not wanting to schlep your CPAP machine back and forth, as well as for peace of mind as a backup in case the primary machine quits or becomes unusable. CPAP users in parts of the country prone to natural disasters and power outages have often learned the hard way that it’s smart to have a CPAP machine with battery capabilities such as the DreamStation Go.
So what exactly is required to obtain a new CPAP?
- CPAP is considered a “legacy” medical device by the FDA and therefore requires a prescription.
- Technically, all you need is a prescription from a qualified medical provider that says “CPAP” (or whatever PAP device is requested, e.g., APAP, BPAP etc.), and the appropriate settings. This will suffice for getting a CPAP machine through a direct-to-consumer channel such as a brick-and-mortar retailer that sells machines for cash or an online CPAP retailer.
- Who qualifies as a qualified medical provider? This article explains who can and cannot prescribe a CPAP machine.
Insurance Requirements for a New CPAP Machine
If you're going through insurance to get a new CPAP, there are more requirements that you'll need to fulfill. Here's what you need to know:
- Five-Year Plan
- Typically insurances will pay for a CPAP machine every five years. If you want a second machine prior to that five-year mark, you'll most likely need to pay out-of-pocket.
- You may need another sleep study
- Many insurance companies require another sleep study if there has been a significant gap since your initial diagnostic sleep study. These days you'll generally have two choices: a home sleep apnea test or an in-lab sleep study (polysomnogram). You may be required to obtain a prior authorization prior to the sleep study; your sleep doctor will have to contact your insurance company and advocate for the medical necessity of the sleep study. The study then must show sleep apnea.
- If you have a more complex sleep-breathing problem, such as central sleep apnea or sleep-related hypoxemia, you may be required to have a second sleep study or be prescribed a more advanced machine such as a BiPAP or ASV.
- Face Off
- The last step is to have a "face-to-face" encounter with your provider to document the medical necessity of the machine and obtain the prescription. An online sleep doctor consultation is now considered to meet the face-to-face requirement, and prescriptions for CPAP machines can be obtained via telemedicine.
Medicare is an odd duck when it comes to getting a new CPAP. You need to know the following if you're trying to obtain a new CPAP machine through Medicare:
- Medicare requires a face-to-face doctor’s visit justifying the sleep study PRIOR to doing the sleep study. Your doctor must document clinical signs and symptoms of sleep apnea.
- In order to cover a CPAP machine, Medicare requires that you have at least moderate obstructive sleep apnea (an AHI of >15) or mild sleep apnea (AHI 5-15) PLUS at least one of the following "co-morbidities:"
- excessive daytime sleepiness
- impaired cognition
- mood disorders
- ischemic heart disease
- history of stroke
- Insufficient usage will lead Medicare to repossess your CPAP machine. To keep your machine, you are required to meet the following criteria: Usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of initial usage.
- If you do lose your CPAP machine and want to get another one, you will have to go through the whole process again starting with another "face-to-face" encounter.
- Note: It is common for private insurers to appropriate Medicare’s CPAP policy as their own policy.
- Medicare does not reimburse you for out-of-pocket expenses so you cannot file a claim and get reimbursed if you buy a CPAP machine for cash.
Joseph Krainin, M.D., FAASM is the founder of Singular Sleep, the world's first online sleep center. He is a Fellow of the American Academy of Sleep Medicine and board certified in both sleep medicine and neurology. He has been practicing medicine for over 10 years.