MEdicare approval??

[Olivia]

My doctor has ordered a new Bipap for me. I have asked for the AirCurve. The DME said that they need MEdicare to fax them a request for that particular machine?? Does MEdicare really have to authorize a particular BiPap? Thanks

[Jas_williams]

My doctor has ordered a new Bipap for me. I have asked for the AirCurve. The DME said that they need MEdicare to fax them a request for that particular machine?? Does MEdicare really have to authorize a particular BiPap? Thanks

It’s your Dr who needs to specify the model/manufacturer , Medicare just pay by model code, make sure the prescription from your Dr specifies exactly the machine you want

[Okie bipap]

It depends on how your prescription is written. If it simply calls for a bi-level machine, then you are at the mercy of the DME. My original prescription called for a ResMed bi-level machine with a range of pressure setting. As a result, the only machine that fit that description is the AirCurve 10 VAUTO. The sleep clinic we use only prescribes ResMed machines.

[chunkyfrog]

My doctor has ordered a new Bipap for me. I have asked for the AirCurve. The DME said that they need MEdicare to fax them a request for that particular machine?? Does MEdicare really have to authorize a particular BiPap? Thanks

Your DME is full of prunes--fully digested, of course.
Ask your doctor or his staff to specify brand and model on the Rx.
Medicare REQUIRES the DME to fill your prescription as prescribed.

[Janknitz]

Medicare does not have to approve the BiPAP but your doctor has to document that you meet the criteria for that machine, and the DME may want that info before they will provide the BiPAP so they don't end up on the hook if the Medicare guidelines are not met.

If you have an HMO advantage plan (Part C Medicare) you may need pre-approval from your advantage plan for the BiPAP, or you may need your Medicare supplement plan to OK it so they will cover the co-pay. Contact your insurance provider to find out whether they require pre-approval.

I think you need to clarify WHO needs WHAT information. It's generally NOT the big Medicare in the sky--they review coverage retrospectively, not prospectively.

[Pugsy]

Is this the same DME that supplied the Respironics BiPap that you currently use?

[Olivia]

Yes, it’s the same DME. It’s actually Nationwide which is mail order. They have sent the request to a local DME provider for distribution who said it needed MEdicare Approval for the AirCurve. When I spoke to Nationwide, they said the doctor just ordered a Bipap. I have had a bait and switch before so just trying to be careful and another accept a machine I don’t want.

[Pugsy]

Tell your doctor you want a specific brand and model machine and he needs to specify it on the prescription so that you won't have a bunch of hassles.

Your insurance pays the same for any bilevel brand but Respironics bilevels costs a little less from the wholesale aspect of it so DMEs will drag their feet when people ask for ResMed brand anything.

So ask your doctor to be real specific
ResMed AirCurve 10 VAuto

The DME probably stocks Respironics machines and will have to special order a ResMed but if that's what you want then accept no substitute.
Medicare doesn't care which brand or model. They have already paid for one bilevel machine so you have already met all the requirements.
Medicare pays by HCPCS billing code alone...not brand or model.

The doctor will have to be specific though and also write "do not substitute" on the RX.

[Olivia]

Thanks everyone.

[chunkyfrog]

DME's like to make you wait for the top level machine--but it is totally worth it.