Insurance Paying For DME After 90 Days

[Dolpp]

My medical insurance goes by the Medicare guidelines, which states,

"For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefit is demonstrated by:
1. Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating physician.
Adherence to therapy is defined as use of PAP > 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.
If the above criteria are not met, continued coverage of a PAP device and related accessories will be denied as not medically necessary.
If the physician re-evaluation does not occur until after the 91st day but the evaluation demonstrates that the patient is benefiting from PAP therapy as defined in criteria 1 and 2 above, continued coverage of the PAP device will commence with the date of that re-evaluation."

My concern is the last sentence, my sleep doctor never made me a follow up appointment. The impression I got from him at my 1 month follow up was that I was almost bothering him because I wasn't miraculously cured and that he didn't want to put any effort into coming up with alternatives. According to how I read this they are going to stop paying for my equipment until I have a re-evaluation with the sleep doctor. I am more than "compliant" according to their criteria. I do feel better, but nowhere near how I should feel. Should I be concerned about this? I don't want to be duking it out with the insurance company, my 90 days is up on July 30th.

[cpapquuen1]

Your right, unless you have a follow-up with your doctor, Medicare will not pay after 90 days. How many days after the start of your therapy did you see the doc??

[cpapquuen1]

Ok, so I went back and read that your insurance follws Medicare guidelines, but you don't have Medicare correct? What insurance do you have??

[Dolpp]

I have Aetna, and I seen my doctor about 5 weeks after starting.

[Janknitz]

Your doctor could really care less if the DME gets reimbursed for the machine or not. He made his money from the sleep study. It's usually the DME that checks compliance, gets some sort of documentation from the doctor to forward to Medicare (or your insurance company) so they can get paid. Despite what the law says, some sleep doctors rarely do a face to face follow-up with the patient. Some sleep doctors never see the patient face to face in the first place.

The DME cares about compliance. To the extent that your compliance is dependent on your comfort and the effectiveness of your therapy, they will care about your comfort and effectiveness so that you are compliant. They will collect the compliance data for you and inform your insurance company.

After that, you are basically on your own unless you are fortunate enough to have a good doctor who does care, or at least one who will listen if you let him know you are not doing well. But it doesn't sound like you have that.

This is why everyone here is so adamant that you have a data capable machine. If you are still tired and not feeling that great, you can use your data to monitor the effectivemenss of your treatment. Don't count on your doctor or DME to do that--you've already seen that they won't. There's no financial incentive for them to ensure effectiveness, only compliance. That's part of our backwards system of healthcare in this country.

[Slinky]

You are safe. You doctor saw you w/in that 90 days. He saw you some 35 days into therapy and that meets the new Medicare requirements. The DME will at some point if they haven't already, download your compliance data so they have the proof on hand should they need to supply it.

Nobdoy but you cares whether you are benefiting from CPAP therapy except you. Not Medicare, not your insurance, not your sleep doctor nor your local DME provider. THEY care only that you are using the CPAP.

[cpapqueen1]

Your fine! Aetna only follows Medciare guidelines to qualify you for the equipment. No compliance necessary after that.