Medicare denies CPAP claim - what next?

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

rested gal wrote:

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.

Wonka wrote:If an Apna Hyponea index of 23.5 is the same as AHI,

Wonka wrote: I would appear the meet the test of an AHI of 15 or greater .

Wonka wrote: I'll talk to my DME tomorrow to see what's going on.

Janknitz wrote:I don't know what the exact stats are these days, Wonka, but I do know that a majority of people who appeal a Medicare denial are successful. I'm sure someone just futzed up somewhere along the way with your documentation and the trick is to identify where it went wrong and get it fixed.

Don't be shy about asking for help from your state's SHIP (State Health Insurance Advocacy Program) program--that is a federally funded organization for Medicare Advocacy. In California it's called "HICAP". The number for your state program should be on the back of your 2011 "Medicare and You" booklet, or you can find it on the Medicare website. That's what they are there for.

rested gal wrote:

Wonka wrote:If an Apna Hyponea index of 23.5 is the same as AHI,

It is.

Wonka wrote: I would appear the meet the test of an AHI of 15 or greater .

You sure did.

Wonka wrote: I'll talk to my DME tomorrow to see what's going on.

Sounds like it might just be a matter of some of the necessary paperwork having not been sent to Medicare by the DME. Good idea to talk to the DME.

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.