Medicare denies CPAP claim - what next?

I received my S9 Autoset w/humidifier 58 days ago, after a two-day sleep study which indicated Apnea and a prescription for an S9 Autoset was written by my Pulmonary Doctor.

Yesterday, I received a letter from Medicare indicating the machine rental, tubing, filter and humidifier denying the claim. In the notes section, the letter indicates "The information provided does not support the need for this service or item." In a second note, it says "It appears that you did not know that we would not pay for this service so you are not liable. Do not pay your provider for this service." Then, the notes quotes references local medical review policy numbers and tells the recipient they can get copies of the policies by calling a number.

I have a great DME (at least from the standpoint of being cooperative), when he brought the unit he included a Climateline hose noting it wasn't on the prescription but was the most desirable to have. Also, I was able to try out (and keep) three masks. He indicated he'd have toss them anyway.

So, I'm very concerned. I would guess since payment to the DME is being denied. They are going to ask for the rented unit back in the middle of my start-up therapy. I couldn't even use it for the first week or so since I was very sick. Now, I'm at 72% usage >4 hours.

I sent a letter protesting this decision immediately with copies of the prescription and the first page of the sleep study which recommends a CPAP with humidifier and supplemental oxygen if the CPAP treatment doesn't improve oxygen saturation.

I don't get it...why does dealing with Medicare have to be so difficult? It's no wonder costs are so high from providers, they have to wait forever to get paid (if ever).

This is very disturbing. Have you contacted your prescribing doctor's office, perhaps they can help with further documentation.

I suspect that your doc does not have something documented correctly. Go to him immediately. You can look up the Medicare requirements on the web for a cpap. Ensure that the items are clearly documented by your physician. Use that documentation, along with the sleep study, and appeal the decision. There shouldn't be a problem.

I'm on Medicare and run into this all the time. I get insurance statements CONSTANTLY saying denied. I don't even bother contacting my DME or doctor anymore. Usually, my DME or doctor has submitted something wrong and since they want to get paid, they fix it on their own.

I can understand why this would be upsetting to you, especially the first time it happens. I rent my ventilator to the tune of $1000 per month and at least half the insurance statements I get for it say denied.

I would contact the DME and have them get the documentation fixed by whoever needs to fix it. It should be fine as scrapper says.

scrapper wrote:I suspect that your doc does not have something documented correctly. Go to him immediately. You can look up the Medicare requirements on the web for a cpap. Ensure that the items are clearly documented by your physician. Use that documentation, along with the sleep study, and appeal the decision. There shouldn't be a problem.

Exactly the reason for people to get their own copy of the sleep study "in hand". Perhaps a copy has not been submitted by your DME? In my case it was because I only had 109 minutes of diagnostic time when 120 minutes are required by Medicare. Your lab & DME should know these things. IF not it is time to find people who do.

Also Medicare has requirements for how many events you must have. You may be better off using the script you have a paying OOP. It may be cheaper than the co-pay.

Good Luck

GumbyCT wrote:

scrapper wrote:I suspect that your doc does not have something documented correctly. Go to him immediately. You can look up the Medicare requirements on the web for a cpap. Ensure that the items are clearly documented by your physician. Use that documentation, along with the sleep study, and appeal the decision. There shouldn't be a problem.

Exactly the reason for people to get their own copy of the sleep study "in hand". Perhaps a copy has not been submitted by your DME? In my case it was because I only had 109 minutes of diagnostic time when 120 minutes are required by Medicare. Your lab & DME should know these things. IF not it is time to find people who do.

Also Medicare has requirements for how many events you must have. You may be better off using the script you have a paying OOP. It may be cheaper than the co-pay.

Good Luck

Since I also have an AARP supplement that pays anything above "Medicare Approved" amounts, I shouldn't pay anything if it's "Approved". I suspect the DME hasn't submitted the required documentation at this time since I just sent in the SD card for the first time January 3rd. I had received an earlier letter from the DME asking for information after 30 days, and they extended it because I started late. So, if the approval required usage data it may be in-transit. I have my first follow-up appointment with my Doc on Friday, January 14th. I'll ask about the letter, but it seems like it's more of a DME issue. My DME was provided a full copy of the sleep study.

As a worst case scenario, I purchased a System One Pro and humidifier with almost no usage as a backup unit some time ago. Although it isn't an auto unit, I've been operating the S9 as a CPAP anyway (the DME changed the setting early in the startup period, but I don't remember why). I also bought a backup Swift LT online. So, if they take back the machine I'll just start using the System One instead.

wonka, please read this and pay attention to my underline:

Other possible costs:

Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your provider offers a wide selection of products that vary slightly in appearance or features.

You may decide that you prefer the products that offer these additional features. Your provider should give you the option to allow you to privately pay a little extra money to get the product that you really want.

To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows patients to upgrade to a piece of equipment that they like better than other standard options they may otherwise qualify for.

The Advance Beneficiary Notice of Non Coverage, or ABN, must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your provider will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket

I excerpted it from this data about Medicare which my DME provided:

Link:

http://www.activehealthcare.com/medicare_insurance.asp


Your story relates to my intent to upgrade the S8 Escape II which I got from them to an S9 Autoset II. As I understand it I'll need to qualify to receive the S9 Autoset II which costs twice as much. If I'll get the S9 I will run it first as a standard CPAP as you're. I plan to talk to my sleep doc about it.

Wonka,

Someone messed up somewhere along the way with either coding the diagnosis or the billing, or the documentation for compliance. You should request the medical review policies to find out the exact basis for the denial and then you will know who messed up what, so they can fix it. Work closely with your DME as they have a vested interest in getting paid.

As for Avi, NO,NO,NO,NO,NO,NO,NO!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Your story relates to my intent to upgrade the S8 Escape II which I got from them to an S9 Autoset II. As I understand it I'll need to qualify to receive the S9 Autoset II which costs twice as much.

NOTE: If you have Medicare Part C, also known as Medicare Advantage, the following does NOT apply.

As far as Medicare is concerned, the S8 Escape II and the S9 Autsoset II are the SAME machine. They are both billed under HCPCs code E0601, and the reimbursement for the machines is EXACTLY THE SAME. Your co-pays are EXACTLY THE SAME. You don't need to "qualify" for the S9. If you qualify for the Escape II, you are automatically qualified for the S9 because it is the same in Medicare's eyes.

If your DME is feeding you this BS that you must qualify and pay more for the S9 Auto, they are lying through their teeth. And they are trying to get extra money out of you. This is called "balance billing" at it is ILLEGAL under Medicare and most state laws. Please see my blog here http://maskarrayed.wordpress.com/what-y ... me-part-i/ and here http://maskarrayed.wordpress.com/dont-p ... -upcharge/

Your biggest problem is that you accepted the Escape II in the first place (I'm not blaming you, your DME took advantage of you by foisting it on you when you didn't know any better). Now, the DME doesn't want to change out your machine because not only will they make much less money on the S9 Auto, but they have now created a used Escape II that nobody wants. But that's their problem NOT yours. Serves them right for giving you that outdated brick (Escape II) in the first place. But you will need to handle this diplomatically, if you want them to work with you.

You will have to buy a new humidifier as the humidifier is an outright purchase under Medicare. But you do not have to pay or "qualify" for the S9--it is NOT an upgrade according to Medicare.

Good luck!

We had to sign the ABN to get an Autoset for my hubby' the DME charged nearly $400 difference.
This is why henceforward, they will only get what business from us that is unavoidable.

chunkyfrog wrote:We had to sign the ABN to get an Autoset for my hubby' the DME charged nearly $400 difference.
This is why henceforward, they will only get what business from us that is unavoidable.

I had to sign a document also. I'm sure it's standard procedure, no?

janknitz, please go over the following and see if you find anything wrong with all of it:

http://activehealthcareinc.com/medicare_insurance.asp

In my opinion, specifying the exact type of CPAP for me is in the hands of one of my doctors. I have yet to meet my SLEEP doctor, but my internist/geriatric gave me an Rx for S8 AutoSet II after I convinced him that it would be an upgrade to my current S8 Escape II. But I have not persued it yet. I am interested to get an S9 Elite which does not offer adjustable Max or Min pressures. As to an S9 AutoSet or an PR System One REMstar BIPAP Auto with BI-Flex, I don't think that my doctors would be exited with pressures autoadj. either. Also, about the Enahnced Autoset Algorithem in the S9 AutoSet, imo, it's too soon to go for it.

My current machine, the S8 Escape II, was prescibed by my internist who works in the same group as the sleep doctor who conducted the sleep study. The presciption to the DME says: CPAP @ 6 cm H2O with expiratory Pressure Relief mode set at 2 (but it did not say Auto-titrating CPAP or Bi-Level IPAP, or Auto Bi-Level ).

So janknitz, you're saying that I should be able to get those more elaborate machines costing almost twice as the S8 Ecape!

If you agree, I am ready to email your manifesto (report) to Lisa Feierstein and ask her what she has to say about it.

This is your report:

http://maskarrayed.wordpress.com/what-y ... me-part-i/

And this Lisa Feierstein, my DME:

Founder Lisa Feierstein, RN, BSN, MBA, has been serving the medical community for more than 25 years in hospital, out-patient and home-care settings, and is a specialist in obstructive sleep apnea.

Lisa's blog:

http://activehealthcareinc.com/blog/

See Lisa here:

http://blog.activehealthcareinc.com/ind ... 6/welcome/

I'm sorry Avi and Wonka..........you've also been held up and robbed regardless of your DME"s credentials.

Janknitz is correct.......

Please feel free to research on this site and Medicare's site for more information...........

There is one code for cpap machines--and the DME can attempt to force anything on you, BUT YOU DO NOT NEED TO SIGN THAT FORM TO PAY EXTRA OR ACCEPT LESSER QUALITY. Go to another DME--vote with your feet. You can get ANY cpap with that prescription WITHOUT paying extra.

avi123 wrote:wonka, please read this and pay attention to my underline:

Other possible costs:

Medicare will pay only for items that meet your basic needs. Oftentimes you will find that your provider offers a wide selection of products that vary slightly in appearance or features.

You may decide that you prefer the products that offer these additional features. Your provider should give you the option to allow you to privately pay a little extra money to get the product that you really want.

To take advantage of this opportunity, a new form has been approved by the Centers for Medicare and Medicaid Services (CMS) that allows patients to upgrade to a piece of equipment that they like better than other standard options they may otherwise qualify for.

The Advance Beneficiary Notice of Non Coverage, or ABN, must detail how the products differ, and requires a signature to indicate that you agree to pay the difference in the retail costs between two similar items. Your provider will typically accept assignment on the standard product and apply that cost toward the purchase of the fancier item, thus requiring less money out of your pocket

I excerpted it from this data about Medicare which my DME provided:

Link:

http://www.activehealthcare.com/medicare_insurance.asp


Your story relates to my intent to upgrade the S8 Escape II which I got from them to an S9 Autoset II. As I understand it I'll need to qualify to receive the S9 Autoset II which costs twice as much. If I'll get the S9 I will run it first as a standard CPAP as you're. I plan to talk to my sleep doc about it.

Unfortunately your DME didn't provide any links directly to Medicare. Hope these links will help, spend some time reading.
http://search.cms.hhs.gov/search?q=abn& ... collection

scrapper wrote:I'm sorry Avi and Wonka..........you've also been held up and robbed regardless of your DME"s credentials.

Janknitz is correct.......

Please feel free to research on this site and Medicare's site for more information...........

There is one code for cpap machines--and the DME can attempt to force anything on you, BUT YOU DO NOT NEED TO SIGN THAT FORM TO PAY EXTRA OR ACCEPT LESSER QUALITY. Go to another DME--vote with your feet. You can get ANY cpap [colorwith that prescription WITHOUT paying extra.

What do you mean by THAT PRESCRIPTION?

the auto bipap requires a different Rx