Medicare & ABN's

krousseau · Post by **krousseau** » Thu Jan 10, 2008 12:59 pm

Have just been introduced to Medicare's Advance Beneficiary Notice process and trying to decide if it is worth the gamble. Anyone out there that has had experience with ABN's or the appeal process. Thinking it might just be better to order the BiPAP from cpap.com.

Have to call BC/BS to see if & what they will pay if Medicare won't.

If I can skip the ABN process, get the BiPAP and send the paid bill and medical necessity documentation to Medicare and see if they will reimburse me.

Any advice?

dllfo · Post by **dllfo** » Thu Jan 10, 2008 7:53 pm

How does Medicare explain their decision NOT to buy it for you?
(EDIT: If I am not being too personal)
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TuckNRoll · Post by **TuckNRoll** » Thu Jan 10, 2008 8:06 pm

There must be a reason that your supplier wants you to sign an ABN, and that must be written on the ABN prior to you signing it. Medicare will pay 80% of an allowed amount and BC/BS will pick up the other 20% of that amount regardless. There are also only certain reasons that a Medicare provider can make you sign an ABN as well, such as not enough medical documentation. They can't just make you sign it just because they want to. If they have not documented the reasoning on the ABN, then you need to insist that they explain why they want you to sign it. Also, as a Medicare recipient, they will not allow you to just send in the bill. A Medicare provider (ie: DME company, some sleep labs) must bill Medicare, the recipient cannot submit bills to Medicare.

Slinky · Post by **Slinky** » Thu Jan 10, 2008 8:06 pm

Fudge! I can't find the URL that lists Medicare's policy on bi-levels (Bi-PAP) but loosely, one must first "fail" CPAP therapy and the doctor must provide a Letter of Medical Necessity along w/the established CPAP failure in order to qualify for Medicare reimbursement for bi-level therapy. I'll betchya RestedGal has the URL at her fingertips or close by tho.

RosemaryB · Post by **RosemaryB** » Thu Jan 10, 2008 8:33 pm

Can you go through billmyinsurance.com? I don't know anything about medicare, but they deal with both medicare and bc/bs.

Slinky · Post by **Slinky** » Fri Jan 11, 2008 5:36 pm

cpap.com has another sister site: cpapforseniors.com, they are the sister site specifically for those one Medicare. However, you have to have not gotten Medicare CPAP benefits from a local DME supplier or must have completed any capped rental for the CPAP machine w/a local DME supplier is my understanding. Its worth a visit to their site and a phone call to them to discuss your situation.

krousseau · Post by **krousseau** » Mon Jan 14, 2008 2:19 pm

I have not ordered the machine yet-but Apria has told me they will issue an ABN based on the fact that Medicare is unlikely to pay because the rental of my CPAP reached its cap in May 2007 and it is too soon to get a new machine.
In reading the Medicare info on ABN's they do say a denial does not mean a person does not need the specific item/service. So it sound like medical necessity is not the only thing they look at. Dr. Guilleminault said that OSA is a progressive disorder. I'm just not sure Medicare will consider me a treatment failure. My AHI at the higher pressures are good but the higher pressure is causing significant problems for me-and I'm not even at max pressure.
I have not yet received the titration report so don't know what the documentation of need looks like yet. When I get all the paperwork I have a list of calls to DME's, Medicare Help Line, BC/BS, and Apria.

What I'm trying to figure out is what will rule the day; Medicare regs or medical necessity. And how much the "gamble" will cost if I lose.

Right Slinky-cpapforseniors won't handle it bacause the CPAP purchase was too recent.

Guest · Post by **Guest** » Mon Jan 14, 2008 4:26 pm

Have you had another sleep study? There are rules to follow for coverage of a BiPAP. Is your primary diagnosis Obstructive Sleep Apnea? If so, The requirements are...
#1- A complete facility based, attended polysomnogram has established the diagnosis of obstructive sleep apnea. AND
#2 A single level device(E0601, CPAP) has been tried and failed.

If both of those requirements are met, an E0470 device will be covered for the first three months of therapy.
**** THe sleep study must show AHI greater than 15 events per hour or AHI of 5-14 with documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia or Hypertension, ischemic heart disease, or history of stroke.

After 3 months of therapy they will need a letter from you and your physician stating that you are benefitting from the machine for continuing coverage.
With out getting too personal on a public website, It is usually safe to assume that you meet the requirements in some capacity. It is part of medicare's requirements that you fail on CPAP. I have never had it be an issue for a patient to change to BiPAP with medicare if they fit the requirements. I hope this information helps. It came from the respironics website, but it is medicare's guidelines. PM me if you have any questions. I hope that I am not being to personal. Let me know if I can help.

krousseau · Post by **krousseau** » Mon Jan 14, 2008 5:15 pm

It not too personal.
I've had a diagnostic PSG and a CPAP titration after which I got a APAP and have been a user since Feb 2, 2006. Generally good AHI but always with aerophagia which at times causing enough discomfort to wonder if it is cardiac-had an angiogram. After they decided it wasn't heart-I stopped complaining about the chest pressure/pain and figured I'd have to deal with it. That in retrospect was probably a mistake as I may have gotten a BiPAP bore the CPAP reverted to ownership. Anyway in the last 4-5 months the numbers started going higher and sleep more fragmented. So called Stanford for a followup. I've had the BiPAP titration and am waiting for the Rx and PSG report. Since Guilleminault is writing the prescription I'm assuming the documentation will support use of the BiPAP-I'm just concerned that Medicare will look at having just paid for the CPAP within the last year and deny the claim.

GumbyCT · Post by **GumbyCT** » Mon Jan 14, 2008 7:09 pm

krousseau wrote:...yet-but Apria has told me they...

So the plot thickens...BiPaps according to Apria!! Let me guess - it will come in the mail - you put it together?
Sorry just could NOT help myself.
And now back to BiPaps on Medicare...

krousseau · Post by **krousseau** » Mon Jan 14, 2008 9:57 pm

Actually-everything Apria said is verified on the MyMedicare website.

And it is even "worse" than getting it in the mail. They have "patients" come in for an appointment at the local oxygen depot they maintain up here in the hills-an RT comes up one day a week for appointments. I get all my info right here or at Stanford, so any questions I ask are geared to make sure I find the appointment amusing.

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