Insurance denied ASV

qjosea wrote:Thank you for the info. I did some research on my own, based on the paragraph Tri-care used to disapprove. Tri-care policy manual Chap. 1, Sec. 2.1 - unproven drugs, devices, treatments, or procedures. I went to the FDA web site and found devices cleared: Feb. 07 510(k) approved
Resperonics , BIPAP ASV , 510(K) NO. K063533, Attn: Zita A. Yurko, SE decision made 20 Feb 2007, 510(k) summary available from FDA. I hope this information and any letter I get form my Dr. Will help me clear this hurdle.

Please include both the direct link (not "summary available from FDA") to the 510(k) and a copy of the approval in any correspondence you have with your insurance company. One thing I've learned about folks like reviewers and auditors is never make them think or look for information.

I called my Dr. yesterday and they said they would take care of it, by calleing APRIA (DME). I did a follow up call to APRIA, they infact did get a call from my Dr.'s office. I asked told that I had limited time to appeal this. They responded with, they would handle it. APRIA said I would recieve a call from them. This doesn't sound kosher. Any one out there ever had a appeal handle by thier DME? Maybe they are going to resubmit with a different Dx. Any comment appreciated.

Thanks,

The DME is who gets the Insurance money for the equipment, so yea it makes sense. Sounds like between the doc & DME the know what the problem is - I would ask each of them.

qjosea wrote:I called my Dr. yesterday and they said they would take care of it, by calleing APRIA (DME). I did a follow up call to APRIA, they infact did get a call from my Dr.'s office. I asked told that I had limited time to appeal this. They responded with, they would handle it. APRIA said I would recieve a call from them. This doesn't sound kosher. Any one out there ever had a appeal handle by thier DME? Maybe they are going to resubmit with a different Dx. Any comment appreciated.

Thanks,

One thought that crossed my mind was if the Doc could legitimately focus on the 'Centrals' & not use the word 'Complex' then he would have the right codes to get the approval. Perhaps he could justify saying he meant to write Mixed Apnea

From the little I know of US code approvals, that is about the only way I can see to get through the gap. But if you have a pro-active Dr & DME, I believe they can do it.

DSM

Tricare has a 60 day timely filing of claims.

I got home and checked my messages, APRIA left a message to call them, by they closed at five. I will call them in the morning, maybe they have good news or maybe not. I will keep everyone posted. Thanks for all the help and support.

Good morning, I will calling my DME apria. I got home late last night and thier offices were closed. I hope they have good news or at the worst I will have to do appeal on my own. Thanks,

Well I spoke with my Dr. and they are going to write a compasionate letter to my insurance company. What it will do, I don't know. My Dr. said to wait until they get the letter out to do my appeal. I will wait for the letter to go thur its path, then I will take on the insurance company myself. I know they are dug in for a fight, well I know I will be able to outflank them and manuver around thier cronies that sit and rubber stamp everything that is put in front of them. DENIED

Can someone out there send me a copy of a format of a appeal letter for a insurance denial . Thanks,

qjosea,

Sorry to hear that they have taken that line but it is no surprise
Again with your Doctor's support it is worth the challenge.

Good luck on this.

DSM

Thank you for your support. If the Dr.'s letter does not work I don't know what recourse I have other that just buy it myself. It is quite expensive, but what price can I put on my health. Hopefully this will all work out for the best.

With your doctor on your side, I think that's great ammo.

qjosea wrote:... If the Dr.'s letter does not work I don't know what recourse I have other that just buy it myself. It is quite expensive, but what price can I put on my health. Hopefully this will all work out for the best. ...

Your positive, but determined attitude will help.

I have personally been reading your post with interest, since I am headed down much the same path. As you might have read, my second sleep study made a huge difference. There should not be any problem, but the price of an AutoSV unit will probably trigger an automatic DENIED.

Your insurance company should have its appeal process clearly documented (on their website). You can also call and ask about it. They must provide you at least the pointers to the appeal process. And it might not hurt to remind them of the consequences of untreated sleep apnea (central or obstructive). It's a matter of protecting the bottom line (now or later). And protecting it now might make their costs significantly higher later, since hospitilization for a heart attack or stroke makes the cost of an AutoSV unit seem to be chump change.

Best wishes on your journey!

qjosea wrote:Thank you for your support. If the Dr.'s letter does not work I don't know what recourse I have other that just buy it myself. It is quite expensive, but what price can I put on my health. Hopefully this will all work out for the best.

I bought my Bipap AutoSV off cpapauctions for ($IIRC 2,500) - got it for a lot less that the quoted price & it only had 1 hour use on the clock !.

Good luck what ever way you go.

DSM

Try this one if you don't get anything else:

http://www.insure.com/articles/healthin ... ppeal.html