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Wonka,
Here is another possibility -

If the supplier isn’t enrolled in Medicare, Medicare won't pay your claim.

From here - http://www.medicare.gov/Coverage/Search ... esults+%3E

Put in your state here - http://www.medicare.gov/Coverage/Home.asp

Wonka wrote: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."

Wonka, I may be wrong, but I don't think it is the autopap (vs "cpap") Medicare is denying. I think they did not receive documentation that you even need any kind of cpap therapy at all.

It doesn't make any difference to Medicare whether the machine you are given is a plain cpap or an autopap... the billing code E0601 covers both, since Medicare considers an autopap to still be "just a cpap" -- a CPAP that can autotitrate, but still (in Medicare's eyes) just a CPAP machine.

If your sleep study didn't come up with an AHI of at least 15, or if it was a split study and not enough time was spent during the first "diagnostic" hours before CPAP was put on you that night, that might be why the claim was denied.

As far as Medicare is concerned, if you didn't score an AHI of at least 15 during your sleep study before CPAP was used, there have to be one of these things also affecting you -- and the doctor will have to document the additional condition.

From this Medicare page (you might have to click an "I accept" button to see it)
http://www.cms.gov/mcd/viewlcd.asp?lcd_ ... how=all#19

INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.

An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:

The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.

The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):

The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,

The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:

Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

Hypertension, ischemic heart disease, or history of stroke.

The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not medically necessary.

Yet more criteria to have met -
The formatting didn't come out right...
The full text is here - http://www.cms.gov/mcd/viewlcd.asp?lcd_ ... 2&show=all

INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.


1. An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:

1. The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.

2. The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):

1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,

2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:

1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

2. Hypertension, ischemic heart disease, or history of stroke.

3. The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not medically necessary.

The formatting didn't come out right...
The full text is here - http://www.cms.gov/mcd/viewlcd.asp?lcd_ ... 2&show=all

I'm thinking it is 50.8 in this link this provider is twisting to "upgrade a cpap"
http://www.cms.gov/BNI/Downloads/RevABN ... ctions.pdf

restedgal,

I see only CPAP and Bi-level in the following coverage by Medicare but not for APAP as the S9 AutoSet is.



INITIAL COVERAGE:

In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.


I.An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:


A.The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea.


B.The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):


1.The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,


2.The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:


a.Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,


b.Hypertension, ischemic heart disease, or history of stroke.


C.The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not medically necessary.


II.An E0470 device is covered for those patients with OSA who meet criteria A-C above, in addition to criterion D:
D.An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).

If E0470 is billed and criterion D is not met, payment will be based on the allowance for the least costly medically appropriate alternative, E0601.

A bi-level positive airway pressure device with back-up rate (E0471) is not medically necessary if the primary diagnosis is OSA; therefore, if E0471 is billed with a diagnosis of OSA, the following payment rules apply:


1.If criteria A - D above are met, payment will be based on the allowance for the least costly medically appropriate alternative, E0470; or,


2.If criteria A-C above are met but not criterion D, payment will be based on the allowance for the least costly medically appropriate alternative, E0601.
If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, substitution of an E0470 does not require a new initial face-to-face clinical evaluation or a new sleep test.
http://www.cignagovernmentservices.com/ ... t_RAD2.pdf
If an E0601 device has been used for more than 3 months and the patient is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin for use of the E0470.

Coverage, coding and documentation requirements for the use of E0470 and E0471 for diagnoses other than OSA are addressed in the Respiratory Assist Devices (RAD) Local Coverage Determination (LCD) and Policy Article (PA).

See also these for the DME to get paid:

http://www.cignagovernmentservices.com/ ... t_RAD1.pdf

http://www.cignagovernmentservices.com/ ... t_RAD2.pdf

Apap's are covered under cpap's............the same with auto bilevel's covered under bilevel's.......... The auto portion makes no difference to Medicare

avi123 wrote:restedgal,

I see only CPAP and Bi-level in the following coverage by Medicare but not for APAP as the S9 AutoSet is.

Right. And the reason you don't see "autopap" or "autotitrating CPAP" or anything that says "auto" in the Medicare coverage is because an autopap IS just a "CPAP" machine, in the eyes of Medicare.

Please reread my post above, where I said this:

rested gal wrote:It doesn't make any difference to Medicare whether the machine you are given is a plain cpap or an autopap... the billing code E0601 covers both, since Medicare considers an autopap to still be "just a cpap" -- a CPAP that can autotitrate, but still (in Medicare's eyes) just a CPAP machine.

As scrapper correctly said:

scrapper wrote:Apap's are covered under cpap's............the same with auto bilevel's covered under bilevel's.......... The auto portion makes no difference to Medicare

CPAP is CPAP is CPAP -- E0601. To Medicare, an "autopap" is nothing more than a CPAP machine.

As Jules pointed out, the only time a machine that has "autotitrating" capability needs a different billing code for Medicare is when it is a "bilevel auto" (like the Respironics' BiPAP Auto, or ResMed's VPAP Auto) since those are not considered "CPAP" machines.

Those two are "bilevel" machines with a different billing code. Even though a bilevel auto can autotitrate if "auto" is turned on, a bilevel auto is actually a "bilevel" machine...not a "cpap" machine. ASV (adapt servo ventilators) are yet another type of machine that have a different billing code from "cpap."

But an autopap, like your ResMed S9 Autoset, avi, is simply a CPAP in Medicare's eyes and doesn't have to be described separately in their coverage info.

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 with that prescription WITHOUT paying extra.

I haven't spoke to my DME yet...But, frankly I don't give a damn what the form said. If they tell me I need to pay for it out of pocket, they can pick it up. I'll use the backup I purchased.

Wonka wrote:I haven't spoke to my DME yet...But, frankly I don't give a damn what the form said. If they tell me I need to pay for it out of pocket, they can pick it up. I'll use the backup I purchased.

I honestly don't think they would have a chance in court to enforce that document. And I think they would back off quickly if Medicare got involved.

[quote="rested gal"][quote="avi123"]restedgal,

CPAP is CPAP is CPAP -- E0601. To Medicare, an "autopap" is nothing more than a CPAP machine.

Thanks RG!

I plan to send you a PM.

You've hijacked another person's thread by asking your question in the middle of someone else's question...but none-the-less, you can research your question to find other's experiences in similar circumstances.

I believe you are renting the machine............You can take your prescription and buy online, probably pay outright for cheaper than any of your out of pocket expenses currently.

Look at the sponsor of this forum: cpap.com for excellent, knowledgeable service. Look too at cpapauction.com or secondwindcpap for other possibilities. They may or may not be covered by your insurance network--but you may still come out ahead.

You're insurance company will kick and scream and threaten...........but check out your options with knowledge from the collective experiences here; the sooner, the better.

Good luck

avi123 wrote:p.s. the bird that you have in your avatar, isn't it a cardinal that belongs to my state?

I grew up in Indiana, where the cardinal is the state bird. I was always surprised as a kid when we drove somewhere far from home and it always seemed that the cardinal was STILL the state bird: Illinois, Indiana, Ohio, Kentucky, West Virginia, Virginia, and North Carolina. If he wanted to, a cardinal could fly from Chicago to Cape Hattaras and never leave his sovereign territory.

[quote="scrapper"]You've hijacked another person's thread by asking your question in the middle of someone else's question...but none-the-less, you can research your question to find other's experiences in similar circumstances.

Reply:

So what if we both have a similar question?

I am on Medicare rental and with BCBS Medigap. So why should I buy anything privately?

Would you guess it that on average a Medicare policy (A+B) is worth half a million dollars?

I don't believe in any legal actions, be it against the DME, insurer, etc.

PIECE!!!

p.s. is your ostrich Kosher (yes, to eat)?

PST wrote:

avi123 wrote:p.s. the bird that you have in your avatar, isn't it a cardinal that belongs to my state?

I grew up in Indiana, where the cardinal is the state bird. I was always surprised as a kid when we drove somewhere far from home and it always seemed that the cardinal was STILL the state bird: Illinois, Indiana, Ohio, Kentucky, West Virginia, Virginia, and North Carolina. If he wanted to, a cardinal could fly from Chicago to Cape Hattaras and never leave his sovereign territory.

PST, when I remarked to RG that the Cardinal does not belong to Tennessee I did know that so many states see it as their state bird. My problem with Cardinals (males) is that when they see their images outside on a glass window they peck on it endlessly.

PST wrote:I grew up in Indiana, where the cardinal is the state bird. I was always surprised as a kid when we drove somewhere far from home and it always seemed that the cardinal was STILL the state bird: Illinois, Indiana, Ohio, Kentucky, West Virginia, Virginia, and North Carolina.

Whaa?? You mean it's not the state bird of Missouri?! Well, maybe that should be Arizona? Gee, I'm so confused here.