Evil DME!

I just called to get supplies mask, filters and hose. When I called she said that I can't get any of it without paying out of pocket since it hasn't been six months and medicare only pays for those items every 6 months. Well by now you probably have guessed it and you are right it is the evil Apria. The reason i am getting a new mask is because i broke the elbow on my f&p 431 and currently have duct tape on it and listenting to it whistle at night. The last time I got a mask was on 7/17/07 and they say i am not eligible for any supplies till 1/17/07. They told me medicare guidelines changed and that you are only eligible for supplies once every six months.

I asked when they changed filters and hose to every six months and she said about a year ago. Who should I contact about this. Because I pulled up on their website and on website for medicare and it clearly shows when I can get one but yet they will not abide by it?

The latest Medicare guidelines that I have been able to find say they will pay for new mask at three months. Headgear is at six, which doesn't make a lot of sense, but in your case that wouldn't matter.

I had a similar battle with my DME, you just have to keep going up the line, requesting to speak with her supervisor, and quoting the information from the Medicare website.:
Go to http://www.cms.hhs.gov/mcd/
Click on "search" (left side)
In Step 1, check Local Coverage
In Step 2, select your state
Check "keyword", type in "continuous positive", and check "title"
Click "search now"
The complete policy is L11528.

Good luck,
Susan

Another good site for answers to Medicare questions is: http://www.cpapforseniors.com

Amos

My contract with my DME had a clause in it that theywould not supply small items. Did not see it until I needed filters, hose, etc. (all small items). Said my mask was only available every 6 months because insurance/medicare only allowed headgear every 6 months and mask could not be purchased with out headgear. Said that if I ordered small items at the same time as a mask they might be able to supply them.

Jerry

Sorry, my ability to copy is limited by my ability to remember things. If you PM me your email address, I will send you the PDF file from Medicare.

HCPCS Code Description Allowed Replacement Frequency
A7030NU Full Face Mask 1 every 90 days
A7031NU Full Face Cushion 1 every 30 days
A7034NU Nasal Mask 1 every 90 days
A7045 Exhalation Port with or without Whisper Swivel Span Not Yet Released By Medicare
A7032NU Nasal Mask Cushion 2 every 30 days
A7044NU Oracle 1 every 90 days
A7033NU Nasal Pillows 2 pairs every 30 days
A7035NU Headgear 1 every 180 days
A7036NU Chinstrap 1 every 180 days
A7037NU Tubing 1 every 90 days
A7039NU Non-Disposable Filters 1 every 180 days
A7038NU Disposable Filters 2 every 30 days
A7046 Humidifer Chamber Span Not Yet Released by Medicare
E0601NU CPAP Varies Greatly - Call For More Information
E0470NU BiPAP Varies Greatly - Call For More Information
E0562NU Heated Humidifier Varies Greatly - Call For More Information
E0561NU Passover Humidifier Varies Greatly - Call For More Information

One thing you can do is call 1 800 MEDICARE and let them know the trouble you are having. Medicare knows who your DME is. They will keep getting away with being dificult if no one reports them. I get patients from certain other DME companies because of their inability to get so called "small supplies" If I can do it so can they.

Well this morning I got a call from the local Apria branch telling me that insurance has approved the mask, and filters but since my insurance only pays for headgear and tubing every 6 months that i will be responsible for those. I asked if BCBS followed medicare guidelines then why is it different now, and she told me that was "MY" contract with BCBS and Apria. Which is total BS. I told them to cancel my order and I would go onlne and purchase and she informed me that I was not allowed that option. I hung up then.

I got off the phone and called my insurance which is BCBS and talked with a phone nurse and she informed me that when they did that they were refusing to fill my order following the guidelines. I asked her if I could put her on three-way so she could verify what they were telling me. Apria told us the same story again and when they were finished the insurance nurse informed her that she was wrong and told them that my order would be paid for following my guidelines which is i pay 10%. of the total order and that since my mask was broken that they are allowed to fufill my order if it is within 30 days of the date i am due for a mask, which it is. You should have heard how nice the lady at Apria was after she heard what the nurse had to say and then explained that my order would be overnighted to me and i should have it in the morning.

Way to go!!! Congrats on a job well done!!!