Insurance Guidelines for Replacement of CPAP Consumables ?

[carbonman]

This has been an interesting thread.....
gives me confidence that, for me, I am on the correct path.

I am on the Aetna/Apria connection.
I have never been able to get a straight answer from Aetna on anything.
Apria is not competent enough to give you a straight answer....
so.... I am equiping myself, out of pocket.
I am fortunate that I am able to do that.
I will continue to pay my monthly rental, which is very reasonable, on my system,
from Apria and will get a new mask on the six month plan.

......BUT, I have been doing very well purchasing new masks and
a new, backup machine on the auction. I would rather pay out-of-pocket and
be self sufficient. It really removes the frustration factor in dealing w/the BORG.

[OldLincoln]

From what I understand most if not all insurance companies follow Medicare guidelines (below).
Of course this is taken from a few documents and only a small part of each (our government at work). I believe it to be accurate and even my ex-DME finally fessed up to follow them. My new one is eager to follow them!

========================================================

ACCESSORIES:
Accessories used with an E0601 device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not medically necessary.

The following table represents the usual maximum amount of accessories expected to be medically necessary:

A4604 - 1 per 3 months: tubing used with a heated humidifier and has a heated wire running the length of the tubing.

A7027 - 1 per 3 months:(Combination oral/nasal mask, used with continuous positive airway pressure device, each)is a two
piece system with separate elements for oral and nasal use.

A7028 - 2 per 1 month: Replacement cushion combination oral/nasal mask.

A7029 - 2 per 1 month: Replacement nasal pillows for combination oral/nasal mask

A7030 - 1 per 3 months: Full Face Mask

A7031 - 1 per 1 month: Replacement cushion for full face mask.

A7032 - 2 per 1 month: Replacement cushion for nasal mask

A7033 - 2 per 1 month: Replacement pillows for nasal mask.

A7034 - 1 per 3 months: Nasal Mask

A7035 - 1 per 6 months: Headgear

A7036 - 1 per 6 months: Chinstrap

A7037 - 1 per 3 months: Tubing

A7038 - 2 per 1 month: Disposable filter

A7039 - 1 per 6 months: Non-Disposable filter

A7046 - 1 per 6 months: Replacement water chamber for humidifier


Revision Effective Date: 01/01/2008
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Usual maximum quantity parameters for new HCPCS codes - A7027, A7028, A7029
HCPCS CODES:
Added: A7027, A7028, A7029

ACCESSORIES
A4604 - Tubing with integrated heating element for use with positive airway pressure device
A7027 - Combination oral/nasal mask, used with continuous positive airway pressure device, each
A7028 - Oral cushion for combination oral/nasal mask, replacement only, each
A7029 - Nasal pillows for combination oral/nasal mask, replacement only, pair
A7030 - Full face mask used with positive airway pressure device, each
A7031 - Face mask interface, replacement for full face mask, each
A7032 - Cushion for use on nasal mask interface, replacement only, each
A7033 - Pillow for use on nasal cannula type interface, replacement only, pair
A7034 - Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035 - Headgear used with positive airway pressure device
A7036 - Chinstrap used with positive airway pressure device
A7037 - Tubing used with positive airway pressure device
A7038 - Filter, disposable, used with positive airway pressure device
A7039 - Filter, non disposable, used with positive airway pressure device
A7044 - Oral interface used with positive airway pressure device, each
A7045 - Exhalation port with or without swivel used with accessories for positive airway devices, replacement only
A7046 - Water chamber for humidifier, used with positive airway pressure device, replacement, each
E0561 - Humidifier, non-heated, used with positive airway pressure device
E0562 - Humidifier, heated, used with positive airway pressure device

ALSO:
A continuous positive airway pressure (CPAP) device (E0601) delivers a constant level of positive air pressure (within a single respiratory cycle) by way of tubing and a noninvasive interface (such as a nasal, oral, or facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs.

For auto-titrating CPAP devices use HCPCS code E0601.
NOTE - CPAP and APAP covered on E0601.

Accessories are separately reimbursable at the time of initial issue and when replaced.
NOTE - This last sentence is why DME's charge kit items separately when new. It's cheaper for them to get the kit and they get the same payment as if they provided the separate parts. But WE get the bag, etc that Medicare and other insurances wouldn't necessarily cover.

[feeling_better]

ACCESSORIES:
Accessories used with an E0601 device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not medically necessary.

OldLincoln, thank you very much for posting this very useful info. Do you know what the above 'coverage criteria' means?

I think there are some variations among different insurance companies. I have BlueCross PPO. One in-network DME simply quoted this for mask. But another in-network DME said I could get a new mask every the 3 month. I think the latter was more accurate. I am beginning to think that if you have the HMO plans, they follow the above Medicare list, but the PPO plans are more liberal. This is only guess on my part at this point.

[6PtStar]

This is what Medicare uses and I was told my BCBS goes by the same schedule. On the schedule for the machine and humidifier I was told that replacement schedule is 5 years unless it is broken and is not cost efective to repair then it is considered on a one on one basis.
.


HCPCS Code Description Allowed Replacement Frequency
A7030NU Full Face Mask 1 every 90 days
A7031NU Full Face Cushion 1 every 30 days
A7034NU Mask 1 every 90 days
A7045 Exhalation Port with or without Whisper Swivel Span Not Yet Released By Medicare
A7032NU Mask Cushion 2 every 30 days
A7044NU Oracle 1 every 90 days
A7033NU Nasal Pillows 2 pairs every 30 days
A7035NU Headgear 1 every 180 days
A7036NU Chinstrap 1 every 180 days
A7037NU Tubing 1 every 90 days
A7039NU Non-Disposable Filters 1 every 180 days
A7038NU Disposable Filters 2 every 30 days
A7046 Humidifer Chamber 1 every 180 days
E0601NU CPAP Varies Greatly - Call For More Information
E0470NU BiPAP Varies Greatly - Call For More Information
E0562NU Heated Humidifier Varies Greatly - Call For More Information
E0561NU Passover Humidifier Varies Greatly - Call For More Information

Jerry

[OldLincoln]

This is the part that precedes my prior post and lays out the requirements. Note the text states "A single level [emphasis mine] continuous positive airway pressure (CPAP) device (E0601) is covered..." This is modified to include APAP in my other post.

==================================
Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

INITIAL COVERAGE:

A single level continuous positive airway pressure (CPAP) device (E0601) is covered if the patient has a diagnosis of obstructive sleep apnea (OSA) documented by an attended, facility-based polysomnogram and meets either of the following criteria (1 or 2):

1) The apnea-hypopnea index (AHI) is greater than or equal to 15 events per hour, or

2) The AHI is from 5 to 14 events per hour with documented symptoms of:

a) Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

b) Hypertension, ischemic heart disease, or history of stroke.

If a claim for a CPAP device (E0601) is submitted and the criteria above have not been met, it will be denied as not medically necessary.

For the purpose of this policy, polysomnographic studies must be performed in a facility based sleep study laboratory, and not in the home or in a mobile facility. These labs must be qualified providers of Medicare services and comply with all applicable state regulatory requirements.

For the purpose of this policy, polysomnographic studies must not be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.

If there is discontinuation of usage of an E0601 device at any time, the supplier is expected to ascertain this, and stop billing for the equipment and related accessories and supplies.

CONTINUED COVERAGE BEYOND THE FIRST THREE MONTHS OF THERAPY:

Continued coverage of an E0601 device beyond the first three months of therapy requires that, no sooner than the 61st day after initiating therapy, the supplier ascertain from either the beneficiary or the treating physician that the beneficiary is continuing to use the CPAP device.

If the above criterion is not met, continued coverage of an E0601 device and related accessories will be denied as not medically necessary.
============================
In my case, my DME had me complete & sign a form stating I am in compliance. Other DME's may want to see proof via a machine data report.

[txnative]

For those on Aetna, you might want to check out the following link to an Aetna document which outlines the policy that Aetna follows.

http://www.aetna.com/cpb/medical/data/1_99/0004.html

After drilling down thru the document you will find that Aetna follows the Medicare DMERC rules with respect to the usual medically necessary quantity of supplies.
Also in this document is the criteria that Aetna uses for Diagnosis and Treatment.

It took me quit a while to find this document. They don't make it easy to get the information we need.
Orig found this stash of documents when I was looking into treatment of a lower back problem.

Enjoy!

[feeling_better]

This is what Medicare uses and I was told my BCBS goes by the same schedule.
Jerry

Hi Jerry, What is BCBS?

[danw61]

Hi Jerry, What is BCBS?

BCBS = Blue Cross Blue Shield

[mymontreal]

Thanks to everyone for posting feedback - interesting reading!

txnative - thanks for finding and posting the link to those "Aetna OSA Guidelines" - I have actually converted the online info to a pdf file for my own reference - if anybody wants a copy of the pdf file, just pm me with your email address.

feeling_better - in my specific situation, I think I agree with you that it may be cheaper to buy supplies through the DME - especially for this year, where my $250 in-network deductible has already been paid - I will however, verify all costs with them before purchasing.

Mike

[gasp]

Having had my Remstar Auto machine with humidifier for a little over a month, I thought I had better find out what guidelines my Insurance company (Aetna) has for replacing/reimbursing consumables (hoses, mask, filters etc).

I do remember that when I originally got my machine from my DME, they had a list of "recommended" replacement timeframes on the wall, but they also made it clear that it all depended on the individual Insurance company.

I called Aetna this afternoon to understand their policies on this & after much research they came back to me and send they have NO recommended guidelines or timeframes on replacing consumable items... is this common, or was I talking to somebody who just did not know ?

After researching, she told me that consumables would be covered AS NEEDED - so if that's true, who determines the definition of "as needed"... ?

I also asked what their reimbursement policy is if I purchase the consumables from an online store (such as cpap.com) rather than my DME - they said that would be ok, but just to remember that I would only be covered at the "Out of Network" rate for those purchases (which is what I expected).

I think I have seen several posts on here stating that it is cheaper to buy online with 70% reimbursement (out of n/w), than to buy through DME with a 90% reimbursement.

Even so, I will need to calculate everything out for the year based on a higher deductible for out-of-network.

IN-NETWORK reimbursed at 90%

OUT-OF-NETWORK reimbursed at 70% BUT with a $500/year deductible.

[ Yes I do have a $250 deductible for IN-Network, but I think that can probably be ignored because... like many folks on cpap I do have a couple of other medical issues - so, I'm going to have to pay my 2009 $250 In-Network deductible anyway, regardless of whether I have cpap or not ]

Does this make sense ? the way I see it, buying cpap supplies online would be my only OUT-of-network activity, so if I buy online, I'm essentially having to pay $500 deductible, which I would not have with DME.

If I know the replacement timelines, I'm guessing I just need to compare DME vs Online prices over the course of 12 months, and compare savings against the $500 deductible.

Any feedback or thoughts would be much appreciated.

Thx
Mike

My insurance company doesn't care how often I get any durable medical supplies, as long as I don't exceed my $5,000 cap per year. I use supplies as follows:
Hose: 1 new every six months
Grey filter: 1 new every six months
Fine filter: 1 new every month
Humidifier chamber: 1 new every six months
Headgear: 1 new every six months
Mask (nasal pillows) 1 new every month
Mask (cushion) 1 new every six months (I use only when asthma flares up and have to use it)

All the above also meets (although I don't need to) the replacement guidelines for many people's insurance companies and the DME's replacement suggested replacement periods. [EXCEPT the mask which most insurance and DME's say can be replaced every two weeks. I find once a month is fine.

Note: It is possible that your Aetna plan is different from other member's Aetna plans.

[qramirez0420@gmail.com]

We have had recent denial from Aetna for A7034-CO97-Denied for the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
N19- procedure code incidental to primary procedure.

Any suggestions?

Thanks

[Goofproof]

We have had recent denial from Aetna for A7034-CO97-Denied for the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
N19- procedure code incidental to primary procedure.

Any suggestions?

Thanks

You are Trolling a 9 year old thread, but I',m sure nothing has changed in only 9 years, it's only the government. Jim

[LSAT]

Insurance companies make their own rules...many follow Medicare guidelines, others do not. Take it up with your carrier.

[TASmart]

We have had recent denial from Aetna for A7034-CO97-Denied for the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.
N19- procedure code incidental to primary procedure.

Any suggestions?

Thanks

Says your DME/Sleep lab are trying to bill twice for the same service, you need to track what specific items are being billed A7034 of for a PAP facemask or nasal cannula. That is supposed to be provided under a already paid package deal. I'd be discussing double billing practices with your DME.

If you call Aetna they will be able to explain what is being denied and what is deemed to have already paid for.