wording of medical necessity letter

Well, I posted a month or so back about which auto to go with - S9elite or the PR. This will be a replacement/upgrade to my 5 year old machine which has no features except ramp. Anyway, I had scheduled with prpovider who got both models in for me to look at. When I got there, she said there may be a problem with my insurance BCBSNC covering it. Seems that BCBS is real stingy with replacements. I really need the new model that has EPR so my doc wrote a letter of med necessity but I don't think the wording is strong enough with regard to the EPR need. After reading the DME policy, I think the wording of the letter could be more focused on the "therapeutic benefit of EPR" for me. The policy is big on NOT replacing or adding on DME that is just for comfort. Nothing has been turned in yet to insurance so I want the dr to get wording that will fit the bill instead of dealing with it after I have taken the machine and would be liable for a big chunk of $$. It just feels like I'm gambling. I have had a conference call with BCBS and home office of provider agency. Of course, nothing is guranteed till the claim goes through. They said go ahead and do it and if more info is needed from doc, they'll ask for it. I'm no medical expert but I can see that the wording is not strong enough after reading the DME policy. The doc has been very helpful but it feels somwhat like I'm overstepping, suggesting wording,etc. In the end,however, its my money on the line and my time!
Any thoughts are appreciated!

A DME policy? Did I read that right? A DME policy should not, I repeat Should NOT be a factor in your healthcare. Call your insurance to find out if you can deal with another DME or buy online.

I am willing to bet that the next DME won't have that policy and will likely give you the machine you want.

I would not be feeding any DME who uses phony policy letters to force a cheaper machine on me. The bottom line is IF your insurance doesn't care why should any DME?

Illegitimi non carborundum.
(Don't let the B**tards wear you down.)

The policy i'm speaking of is the Durable Medical Equip policy from my insurance company BlueCrossBS - not the provider company. Sorry for the confusion.

HPM wrote:The policy i'm speaking of is the Durable Medical Equip policy from my insurance company BlueCrossBS - not the provider company. Sorry for the confusion.

Ask IF you can use another DME.

I have had BCBS in Michigan, so their policy might be different than yours, but I had no problem getting what I wanted simply by shopping for a DME that would give it to me. The first DME said that I couldn't get a S9 because they were not available yet (actually because they still had S8s in stock). The second DME said that BCBS would not replace the CPAP simply because it had been 5 years since the last one and my then current machine actually had to be broken before it could be replaced--another dummy. The 3rd DME told me that he didn't have the Autoset in stock, but would have it in a week, no problem with the BCBS.

As other have said, make sure it is truly BCBS policy, not DME policy.

GumbyCT,

Please carefully re-read both of the posts by HPM: His problem is NOT with his current DME. His problem is that his insurance company has really lousy coverage for replacement of aging, but still functioning durable medical equipment such as his current 5 year old machine.

It is Blue Cross Blue Shield that is doing the foot dragging here and saying that they will only pay for the new machine if the doc provides a sufficiently detailed/strongly worded letter of medical necessity. And HPM is worried that the current wording of the letter will allow BCBS to conclude that he doesn't really need EPR to improve his therapy, but rather that he merely wants EPR to improve his comfort. And that BCBS will then deny the claim after he's picked up the machine from the DME.

robysue wrote:GumbyCT,

Please carefully re-read both of the posts by HPM:

robysue,
Please read the post right above yours.

yawnny wrote:I have had BCBS in Michigan, so their policy might be different than yours, but I had no problem getting what I wanted simply by shopping for a DME that would give it to me. The first DME said that I couldn't get a S9 because they were not available yet (actually because they still had S8s in stock). The second DME said that BCBS would not replace the CPAP simply because it had been 5 years since the last one and my then current machine actually had to be broken before it could be replaced--another dummy. The 3rd DME told me that he didn't have the Autoset in stock, but would have it in a week, no problem with the BCBS.

As other have said, make sure it is truly BCBS policy, not DME policy.

It is Blue Cross Blue Shield that is doing the foot dragging here and saying that they will only pay for the new machine if the doc provides a sufficiently detailed/strongly worded letter of medical necessity. And HPM is worried that the current wording of the letter will allow BCBS to conclude that he doesn't really need EPR to improve his therapy, but rather that he merely wants EPR to improve his comfort. And that BCBS will then deny the claim after he's picked up the machine from the DME.

HPM said that the "DME policy" reads . . . I'm assuming (as did Roby Sue) that you mean BCBS's policy for DME. Can you quote exactly what the policy says? And what document are you reading this from?

The gospel is written in your "Evidence of Coverage" document--that's the actual legal contract between you and your insurer, but most people never see this document unless they specifically ask for it. So if that's not what you're quoting from, be sure to request a copy of the EOC in writing. In most states, state law requires an insurer to provde a copy of the evidence of coverage document to an insured within a certain number of days of the written request. In California, that's 10 days. Whatever it says in whatever BCBS document you're reading from, if it's not in your EOC, it may not be true.

Is BCBS your primary insurer, or are you on Medicare with a BCBS supplement?

Don't worry about overstepping--doctors rely on DME's all the time to give them the "magic words" needed for a patient to get coverage fro DME.

Also, just to make sure you are aware that a REsMed Elite is NOT an auto machine. I'm guessing you know that, but you first sentence says otherwise.

about which auto to go with - S9elite or the PR

Blue Cross? BS!!!!!!

My doc has to talk to them on a regular basis. They will do what your doc wants, if he insists. They just want their pound of flesh first.

HPM wrote:They said go ahead and do it and if more info is needed from doc, they'll ask for it. I'm no medical expert but I can see that the wording is not strong enough after reading the DME policy.

What would be extremely helpful here is for us to see (know) what the wording says in each of these documents. Lacking that your doc could write that due to increases in your ahi in different sleeping positions you require an auto adjusting cpap and then specify the make & model.

HPM wrote:I have had a conference call with BCBS and home office of provider agency.

Unless you dialed the insurance folks for that so called "conference call" - my guess is the DME is leading you down the path to the outhouse. Could both voices have been DME employees?

But even still w/o seeing/knowing what is fact and what is DME BS this is like throwing darts in the dark.

My gut tells me that your DME knows that you put up with this brick for 5 yrs. w/o a gripe and they will do what ever it takes to keep you in the dark again or still for the future.

HPM wrote:she said there may be a problem with my insurance BCBSNC covering it. Seems that BCBS is real stingy with replacements.

As of 2011 my BCBSNC policy pays for no CPAP equipment at all. None the first time you are diagnosed. No replacements ever. No masks, no machines, no hoses. It is very clear in the benefits summary manual.

Your NC policy may be different - they sell a variety of policies. Check the exact wording.

This is one of the reasons I would like to see machines become OTC. The requirement that sellers must be licensed DMEs also needs to be dropped.

I saw people on here writing that the machines/supplies should be deregulated and sold at WalMart, Sam's, Best Buy, Target, and Joe's Local Variety Store and the prices would drop dramatically. People could also sell used ones on EBay and the availability and price of used ones would be very good for us patients.

VVV wrote:

HPM wrote:she said there may be a problem with my insurance BCBSNC covering it. Seems that BCBS is real stingy with replacements.

As of 2011 my BCBSNC policy pays for no CPAP equipment at all. None the first time you are diagnosed. No replacements ever. No masks, no machines, no hoses. It is very clear in the benefits summary manual.

Your NC policy may be different - they sell a variety of policies. Check the exact wording.

This is one of the reasons I would like to see machines become OTC. The requirement that sellers must be licensed DMEs also needs to be dropped.

I saw people on here writing that the machines/supplies should be deregulated and sold at WalMart, Sam's, Best Buy, Target, and Joe's Local Variety Store and the prices would drop dramatically. People could also sell used ones on EBay and the availability and price of used ones would be very good for us patients.

It must be just your policy. Here is BCBSNC's own pdf which includes its policy:

http://www.bcbsnc.com/assets/services/p ... evices.pdf


.

taberge wrote:

It must be just your policy. Here is BCBSNC's own pdf which includes its policy:

http://www.bcbsnc.com/assets/services/p ... evices.pdf


.

You have linked to BCBSNC's Corporate Policy.

HPM and I cannot determine from this policy what is covered under our plans. BCBSNC states in the Policy:

Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

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