Denied AGAIN

[lanndi]

With such a low AHI, I can understand an insurance company questioning the need for a machine. They usually have standards like you need to have an AHI of 15 before an APAP will be approved. So "on paper" you look like you don't need a machine -- and they don't have systems for unusual cases such as yours. Fingers crossed for your doc's call w/ medicaid!

[cpapjr]

I konw money is tight but you can get a new CPAP now for 200 to 300 dollars. Try one on those for now if you can get the money for it. At lest it will get you started. The mask or course is extra but I've seem some for as low as $49.00.

Thanks

[mattman]

Hi. I fully appreciate and understand how frustrating this all is.

You obviously have a slightly unusual situation and you need to be working closely with BOTH your doctor and your DME provider. Quite possibly even more so with your DME provider since they will not only have the billing expertise but also the social expertise to be able to hook you up with local service organizations that may also be able to help you out. It's a large part of what we do.

That said, here is some information you need to know. You should be able to get a Bi-Level machine that would qualify under medicare code E0471 - Respiratory Assist Device. You *DO NOT* want to be trying to get your equipment covered under the CPAP code of E0470.

Here's why: E0470 absolutely requires either an AHI of 5-14 with extenuating circumstances or 15+ without. Period. End of story. No matter what else you have going on if you don't hit an AHI of 5 it'll never get covered.

BUT - and here's where it's important to you - a Bi-Level machine can qualify in many cases as E0471 and once that happens you have a whole world of thoracic issues that qualify you. Specifically, here's the section out of the Wisconsin Medicare manual and Medicaid - while often different - should be fairly close to this:

For an E0470 or an E0471 RAD to be covered, the treating physician must fully document in the patient’s medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc.

A RAD (E0470, E0471) is covered for those patients with clinical disorder groups characterized as (I) restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities), (II) severe chronic obstructive pulmonary disease (COPD), or (III) central sleep apnea (CSA), and who also meet the following criteria:



Restrictive Thoracic Disorders:


There is documentation in the patient’s medical record of a progressive neuromuscular disease (for example, amyotrophic lateral sclerosis) or a severe thoracic cage abnormality (for example, post-thoracoplasty for TB), and
1) An arterial blood gas PaCO2 , done while awake and breathing the patient’s usual FIO2 is greater than or equal to 45 mm Hg, or

2) Sleep oximetry demonstrates oxygen saturation less than or equal to 88% for at least five continuous minutes, done while breathing the patient’s usual FIO2, or,

3) For a progressive neuromuscular disease (only), maximal inspiratory pressure is less than 60 cm H20 or forced vital capacity is less than 50% predicted, and
Chronic obstructive pulmonary disease does not contribute significantly to the patient’s pulmonary limitation.


If all of the above criteria are met, either an E0470 or an E0471 device (based upon the judgment of the treating physician) will be covered for patients within this group of conditions for the first three months of therapy. (See Continued Coverage Criteria for E0470 and E0471 devices beyond the first three months.)

If all of the above criteria are not met, then E0470 or E0471 and related accessories will be denied as not medically necessary.

Here's a direct link to the entire section. Note that this is for Wisconsin!
http://www.ngsmedicare.com/NGSMedicare/ ... ve_lcd.htm

This is why I suggest to talk to your equipment provider. They can try to get with your doctor to get the specific items needed to try to qualify you.

I really hope that helps!

mattman

[GumbyCT]

Perfect Matt, I think she lives in Wisconsin. This should be a tremendous help.

You da Mattman