Replacement Schedules?

[Kiralynx]

OK, I know I've seen stuff on Medicare replacement schedules for modestly useful items like nasal pillows and cushions, not to mention masks, filters, and hoses.

Space... the final frontier. It's in between my ears.

I'm not finding any of them. Again.

After this week's Fiasco of No Local Insurance Covered DME Having Supplies in Stock, and having to emergency order a mask from CPAP,COM so that I didn't have to do without my Bipap for more than two nights because my current respiratory infection makes use of nasal masks impossible, I finally got hold of my husband's HR people and managed to beat my way through the layers of security.

A patient advocate will be calling me tomorrow. We may get reimbursed for the mask from CPAP.COM, since, according to the preliminary advocate, they should have had something useable in stock. IE, I should not have to do without my Bipap, and if they wanted an additional prescription for an "out of cycle" mask, they should have told me to get one from my physician instead of telling me I didn't need another mask because I had one which worked, and my insurance wouldn't pay for one until 28 April.

I've been asking for a full face or oral mask because I know what happens when I get a respiratory infection. They've been telling me I couldn't have another mask.

Anyway...

I know that every insurance company's replacement schedule may differ. BUT: can someone point me to the Medicare replacement schedule, which could serve as a useful guideline for tomorrow's discussion?

Any additional thoughts or suggestions relating to this discussion (and which might help someone else to be prepared with back-up masks and supplies for unexpected health crises) would also be appreciated.

Thanks in advance.

[OutaSync]

Is this what you are looking for?

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.

[Kiralynx]

Thank you!

That IS what I was looking for!

Do you know if it's the same scheduling for those of us with the fancy Bipap Auto SVs, or if there are other codes involved?

[alexcue]

that replacement schedule seems identical to the list that Apria gave me for Kaiser's coverage. They just gave me a nice yearly schedule to make sure i called in for my stuff.

[Kiralynx]

that replacement schedule seems identical to the list that Apria gave me for Kaiser's coverage. They just gave me a nice yearly schedule to make sure i called in for my stuff.

My local Apria apparently does not want me to know when I can order things and when I cannot.

Which is why I did not have a back-up mask for this current illness.

[JoyD.]

Kiralynx,

States differ for Medicare replacement schedules. For example, here in Kentucky Medicare will only replace a mask every 6 months, not 3 months.

Better check your own state Medicare schedule. A good DME SHOULD know it, mine gave me a printout.

Joy

[OutaSync]

Thank you!

That IS what I was looking for!

Do you know if it's the same scheduling for those of us with the fancy Bipap Auto SVs, or if there are other codes involved?

As far as I know the only thing that would be different would be the codes for our machines. Filters, hoses and masks are the same.

[Babette]

BTW, that's the MEDICARE schedule. Alot of insurance companies will go by that. But some won't. You need to check with your individual insurance before using this as gospel.

Me, I THINK from all my discussions with them, that my insurance will pay for anything I submit. But if *I* submit it, I'll only get 70% back. But I could buy a new mask every month and get that 70% back. I keep to about once every six months, and if I want something in between, I usually just go out of pocket on it. Unless it's huge.

So, be sure to check with your insurance directly.

Cheers,
B.

[Kiralynx]

BTW, that's the MEDICARE schedule. Alot of insurance companies will go by that. But some won't. You need to check with your individual insurance before using this as gospel.

Me, I THINK from all my discussions with them, that my insurance will pay for anything I submit. But if *I* submit it, I'll only get 70% back. But I could buy a new mask every month and get that 70% back. I keep to about once every six months, and if I want something in between, I usually just go out of pocket on it. Unless it's huge.

So, be sure to check with your insurance directly.

I know that's the Medicare schedule. AND I know that each state is different. Trying to find ANYTHING on Louisiana is worth your life, since Louisiana is also Napoleonic Code instead of English Common Law.

MY insurance is, by what I understand, supposed to pay for anything the doctor gives me a prescription for. They didn't even blink over the Bipap Auto SV, and I didn't even have a co-pay on it. (Of course, we'd pretty well done in our deductable with my cancer surgery earlier in the year....)

Problem is -- the DME will not tell me what I'm allowed. The insurance will not tell me what I'm allowed. They will not tell me how to submit a claim of my own -- they just say to go through the DME. The DME, however, ignores anything they don't think I need, including the prescription from my previous PCP for additional data cards until I could arrange to save data with MyCPAP.Org's utility and a PDF printer driver. The insurance also says they just administer the benefits plan, and I have to talk to the Human Resources at my husband's company.

I have finally beaten my way through the layers of security, and an advocate is supposed to call me tomorrow.

So I'm trying to be prepared.

[Babette]

It took me HOURS on the phone with my insurance, talking to NUMEROUS different people to finally get the answer I did get.

Right now I'm just sort of winging it. I've discovered they will happily pay every six months when I buy a mask and supplies. This last order, I got two different chinstraps. I'm waiting to see if they will pay for both of these. I also ordered filters for a machine I didn't buy through them. Wondering if they will notice that.

And now and then they hiccup and try to contact cpap.com instead of me.

Does your insurance have a website? Mine has a form on their website that I can download and print out for submitting my claims. Lucky me - I have a copy of Adobe Pro, so I can even turn it into a typable form. God forbid they would do that for me...

Don't get me wrong. They don't pay promptly. Takes them anywhere from 1-3 months to pay me. Depends which particular idiot opens the envelope, I guess.

BEST OF LUCK!!!!
B.

[Kiralynx]

It took me HOURS on the phone with my insurance, talking to NUMEROUS different people to finally get the answer I did get.

<snip>

Don't get me wrong. They don't pay promptly. Takes them anywhere from 1-3 months to pay me. Depends which particular idiot opens the envelope, I guess.

Well, I've been trying to find out for five months now what's covered. For a number of things -- like Pad-a-Cheek, and all, it's just easier to pay out of pocket. I've also paid out of pocket for a couple of direct seals after the Grand Fiasco of Shipping the Direct Seals in a Plain Paper Envelope and Then Acting Surprised When It Arrives Crushed....

But see, even by the DME's reckoning, I'm due for a new mask. I'm coming up on six months. And I have a feeling that the mask they've ordered -- which has not arrived yet -- they're going to try to claim is my six month replacement. By the time their bleeping mask gets here, I'll be well!

I'm royally ticked, because if we hadn't had the room on the credit card to place that order with CPAP.COM, I would now be facing my fifth night without my Bipap... and I by D@MN am not going to have someone say I'm non-compliant when I cannot use the machine because they wouldn't give me a mask that works when I have a respiratory infection! Besides that, I hurt too blasted much without it!

[Kiralynx]

States differ for Medicare replacement schedules. For example, here in Kentucky Medicare will only replace a mask every 6 months, not 3 months. Better check your own state Medicare schedule. A good DME SHOULD know it, mine gave me a printout.

Joy,

I know the states differ, but have not yet found the Louisiana CPAP information. A good DME should know it. Mine has not given me a copy of it.

I'm not on Medicare... I mainly wanted the Medicare guideline as, well, a guideline, for my discussion with the advocate tomorrow.

If I can say, "Medicare typically allows...." that sounds better than "I want..."

[Babette]

I'm with you on that Kiralynx. I think if you drill down, Medicare allows a new "seal" or "cannula" every 3 months, but a new entire mask only every 6 months.

Your DME will NEVER tell you the actual schedule. Or if they do, they will lie to you. That's my personal experience.

What I finally got my insurance to admit is that they will pay for anything, any time it's submitted by a DME. Most DME's don't want to wade through the fine print of every different insurance reg, so they just default to the Medicare schedule, which is what I'm pretty much reading here.

Now with me buying out of pocket and submitting, I decided to just wing it and see what they would pay when. So far, they are paying for everything that I order on a six months schedule. And if I order supplies in between, they will pay for those too, but it just takes longer. If I wait and order everything in October or April, it seems to make them happiest and they pay faster and smoother.

Huggers,
B.

[6PtStar]

Kiralynx,

States differ for Medicare replacement schedules. For example, here in Kentucky Medicare will only replace a mask every 6 months, not 3 months.

Better check your own state Medicare schedule. A good DME SHOULD know it, mine gave me a printout.

Joy

Joy, I got caught in that 3 month thing. They told me that yes I could replace the mask every 3 months but the headgear is replaceable only every 6 months. The kicker was that they won't sell the mask without the headgear so that puts you in the 1 every 6 months catagory. If they sold the mask without the headgear you could actually get 1 every 3 months.

Jerry

[Kiralynx]

Wonder why I feel I'm being handed more bureaucratic BS?

Spoke with the "advocate" today... and was told I had to talk to the insurance company.

I told the very nice lady that I had spoken to the insurance company, and they told me I had to talk to my husband's employer's HR department.

There was lots of blah-blah-blah about "reaching out" and so forth.

I frankly don't care about feel-good-speak. I want to know what the replacement schedule for my insurance is, whether I can get repaid for emergency supplies, and a more efficient way of getting emergency supplies.

THE DME-ordered mask ambled in last night... four days after I ordered it.

If I hadn't gotten the mask from CPAP.COM, I would now be almost a week without my therapy.

I am seriously NOT impressed.