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Fight with medical group- third round
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bwexler Offline

Advisory Members

Posts: 563
Joined: Mar 2012

Machine: PRS 1 BiPAP autoSV Advanced, with Heated Tube humidifier
Mask Type: Nasal mask
Mask Make & Model: Sleepweaver Élan
Humidifier: Resperonics Heated Tube humidifier
CPAP Pressure: Max pressure 25.0 cm H20, Max
CPAP Software: SleepyHead EncorePro

Other Comments: CMS 50i with Software for SpO2

Sex: Male
Location: San Marcos, CA, USA

Post: #1
Fight with medical group- third round
Today I received the rejection letter from the medical group that must approve the new soft cushion for my Seepweaver Élan mask.
The reason: It is not medically necessary under Medicare guidelines, it is only for my personal convenience.

I guess that is true I do find it convenient to breathe at night.

So starts the third round. I requested a referral to a sleep doctor to verify that breathing is not just convenient but also a medical necessity.

At least I got the response late on Friday afternoon so I can fret about it over the weekend.
06-21-2013 07:55 PM
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Paptillian Offline

Preferred Members-2

Posts: 474
Joined: Jun 2013

Machine: S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: Swift FX
Humidifier: H5i
CPAP Pressure: 4 - 10, EPR x2
CPAP Software: ResScan SleepyHead

Other Comments:

Sex: Male
Location: Pennsylvania, USA

Post: #2
RE: Fight with medical group- third round
Doesn't it fall under one of the standard HCPC codes for mask cushions?
06-21-2013 10:04 PM
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Shastzi Offline

Advisory Members

Posts: 1,174
Joined: Dec 2012

Machine: ResMed S9 Autoset
Mask Type: Full face mask
Mask Make & Model: FitLife Total face mask
Humidifier: F&P HC150 with Hybernite heated hose.
CPAP Pressure: 15cm-20cm H2O (auto)
CPAP Software: SleepyHead Other Software

Other Comments: CMS50-F wearable Oximeter; Software: SPO2 Assistant

Sex: Undisclosed
Location: Florida, USA.

Post: #3
RE: Fight with medical group- third round
Nope. Sorry. We therefore suggest that you not breathe.
If however you find you MUST breathe, try not to make a habit of it.

Smile

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
06-22-2013 04:43 PM
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bwexler Offline

Advisory Members

Posts: 563
Joined: Mar 2012

Machine: PRS 1 BiPAP autoSV Advanced, with Heated Tube humidifier
Mask Type: Nasal mask
Mask Make & Model: Sleepweaver Élan
Humidifier: Resperonics Heated Tube humidifier
CPAP Pressure: Max pressure 25.0 cm H20, Max
CPAP Software: SleepyHead EncorePro

Other Comments: CMS 50i with Software for SpO2

Sex: Male
Location: San Marcos, CA, USA

Post: #4
RE: Fight with medical group- third round
(06-21-2013 10:04 PM)Paptillian Wrote:  Doesn't it fall under one of the standard HCPC codes for mask cushions?

Yes it does. They actually approved it once, but the DME could not/would not work with Circadiance. When said lets get a different DME, that is when they denied it.
06-24-2013 12:45 PM
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Shastzi Offline

Advisory Members

Posts: 1,174
Joined: Dec 2012

Machine: ResMed S9 Autoset
Mask Type: Full face mask
Mask Make & Model: FitLife Total face mask
Humidifier: F&P HC150 with Hybernite heated hose.
CPAP Pressure: 15cm-20cm H2O (auto)
CPAP Software: SleepyHead Other Software

Other Comments: CMS50-F wearable Oximeter; Software: SPO2 Assistant

Sex: Undisclosed
Location: Florida, USA.

Post: #5
RE: Fight with medical group- third round
Ultamatum time.
"Either you figure out a way to work with me so I get what I need, or I find someone else who will!"
Then turn on your heel and head towards the door.

They will either recant or let you go. Either way it's win-win for you.

"With ordinary talent and extraordinary perseverance, all things are attainable." - Thomas Foxwell Buxton

Cool
06-24-2013 03:14 PM
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