Medical Necessity ?

[Nite Ranger]

Late March 2014 I had a sleep study at a clinic ordered by my pulmonologist/sleep Dr. results were base ahi-67.5, lowest SaO2-78%,rdi-60.5 per hr.,37-apneas,103-hypopneas,6-reras, recent 6 mo. follow up with Dr. went well, he took me off nightly supplemental O2 after an o/nite pulse-ox test that was good a month previous, ihad lost 30 lbs. (diet/exercise) other than 5 days over 7 mos. due to power outages ive been totally compliant. Now today i recieved a statement from bcbsil stating i owe dme $289 mo. rental for machine because its NOT MEDICALLY NECESSARY denial code 355 im a bit confused right now,thanks for a place to vent, i guess im done

[BlackSpinner]

Which machine? the O2 generator or the xpap?

You probably need to get in touch with your doctor and find out what he wrote to them.

[kteague]

Wow. That's frustrating. Often insurances will attempt to deny coverage in hopes the insured will just accept it. There was a thread on this subject several years ago. Seems with some insurances it's standard business practice - deny, deny, deny. There's usually an appeals process and your doctor will likely need to submit a statement to them with supporting documentation that your services were medically necessary. I'm guessing you'll win this one, but a royal hassle for sure.

[Nite Ranger]

Which machine? the O2 generator or the xpap?

You probably need to get in touch with your doctor and find out what he wrote to them.

bipap was just deemed unecessary by bcbsil after 7 mos. of covering it ,Dr. didnt change anything with bipap only terminated O2 usage, thanks for the reply

[Wulfman...]

Which machine? the O2 generator or the xpap?

You probably need to get in touch with your doctor and find out what he wrote to them.

bipap was just deemed unecessary by bcbsil after 7 mos. of covering it ,Dr. didnt change anything with bipap only terminated O2 usage, thanks for the reply

Sounds like somebody screwed up, somewhere. You need to check with the insurance and backtrack to DME and doctor.
I'm suspecting the DME is the culprit.

Good luck.


Den

.

[cnaumann]

This is a regarding a BiPAP machine? I don't know what state you are, but try to see if your blue cross coverage policy about Noninvasive Positive Pressure Ventilation is online and read it carefully. If not, request a copy.

Here in Alabama, Blue Cross requires that you demonstrate that you have tried CPAP to treat sleep related respiratory events and that CPAP has been proven ineffective before they will consider covering BiPAP. This can be due to patient intolerance, or the fact that respiratory events were evident at pressures over 10cm h2o. My hunch is that Blue Cross does not have the reason you not on CPAP documented. It is likely that your doctor can forward the information to the DME provider and they can clear the whole thing up.

Under no circumstances pay the bill unless ordered to do so by a judge. Once the bill is paid, both you DME provider and Blue Cross will consider it a closed matter and you will never be reimbursed even if you submit all the correct documentation. Of course, if you feel that you owe the money, go ahead and pay.

[borgready]

So I was thinking about getting a new machine. The DME told me that you rent the machine on a month to month basis untill its paid off. If you don't follow their compliance rules then they don't pay no more rent and then you stuck with paying for the machine. I think the DME was saying that the compliance requirements were like 4 consecutive hours every night. Not a total of 4 hours, but 4 hours in a row of non stop use. This sounds like to me a way to get out of paying for the machine. Their supposed to cover the medical devices 80/20 but you now have to meet the requirements or they don't pay. The insurance is Anthem. Sounds like a scam their running now.

My question is if you go with an out of network company like cpap.com and get your bipap machine there and pay for it up front and then file a claim for it where they should reimburse you for the amount they owe(80%), how do they handle that now. What is required from the doctor if they request a letter of medical necessity? Has anyone tried filing a claim with anthem for a machine you paid for upfront with in the last year.

[chunkyfrog]

United Health (doesn't) Care would do that stuff at the drop of a hat.
Our union demanded their contract not be renewed.
Worst bunch of weasels I ever saw!
--and they actually have the cheek to think I might consider them for my Medicare supplement.
Uh, NO!

[cnaumann]

Over the years, I have probably filed a half a dozen claims with Blue Cross Blue Shield of Alabama where I was forced to pay an out-of-network provider cash up front for services. I don't believe Blue Cross has ever reimbursed me for any of them.

It annoys the stew out of me that question the medical necessity of anything. If a doctor orders it, especially one of their network doctors, it is their job is to pay for it. It is that simple.