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Health Net and ASV
#1
According to their National Medical Policy on ASVs (not enough posts to link to it), Health Net considers ASV unproven and not a medical necessity. Does this apply to E0471 as a whole? Anyone have experience with them and an ASV machine?
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#2
Hi iSnore,
WELCOME! to the forum.!
I don't know the answer to your question but hang in there, I'm sure someone does.
Much success to you.
trish6hundred
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#3
(04-08-2015, 08:47 AM)iSnore Wrote: According to their National Medical Policy on ASVs (not enough posts to link to it), Health Net considers ASV unproven and not a medical necessity. Does this apply to E0471 as a whole? Anyone have experience with them and an ASV machine?

They're an insurance company and their opinion of "medically necessary" is irrelevant.

Ventilator technology is not new, is FDA approved for the purpose, and if you need it, they don't get to say "no", even if it means you have to get a lawyer and beat them into it.

I can see them rejecting it if you don't actually need it, but if you do, that just sounds bizzare. If you were in a hospital and needed to be on a ventilator, would they say that was "not medically necessary" also?





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#4
Health insurance is a business, and you not "needing" a "special" machine means more money in their pockets. If a health insurance company or DME tells you the sky is blue you better darn well go check for yourself.
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#5
Thank you all for the responses. I'm finding that the machine you get is really between you and the DME, as long as they use the appropriately justified billing code. I'm looking forward to my first sleep doctor appointment Tuesday.
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#6
(04-08-2015, 08:47 AM)iSnore Wrote: According to their National Medical Policy on ASVs (not enough posts to link to it), Health Net considers ASV unproven and not a medical necessity. Does this apply to E0471 as a whole? Anyone have experience with them and an ASV machine?

Perhaps that is true in the case of an OSA diagnosis, but not in the face of a CA diagnosis?
هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
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#7
(04-09-2015, 12:32 PM)DariaVader Wrote:
(04-08-2015, 08:47 AM)iSnore Wrote: According to their National Medical Policy on ASVs (not enough posts to link to it), Health Net considers ASV unproven and not a medical necessity. Does this apply to E0471 as a whole? Anyone have experience with them and an ASV machine?

Perhaps that is true in the case of an OSA diagnosis, but not in the face of a CA diagnosis?

Thanks for that observation. I'm thinking in the case of CA, HN would approve a prescription written for a "bilevel with backup rate" since a non-ASV AirCurve ST provides that. And since the ST and ASV are both E0471, they'd pay for the ASV if that's what the DME provided in lieu of the ST.

BTW, if you Google "Health Net ASV" the NMP on ASVs should be the first find. Their medical justification is laughable.
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#8
Current Policy Statement
Health Net, Inc. considers adaptive servo-ventilation for the treatment of central or complex sleep apnea investigational due to insufficient evidence in the peer review published literature demonstrating its long- term safety and efficacy.


yeah, laughable, especially as they go on to explain the recommendations to the opposite effect
هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
Tongue Suck Technique for prevention of mouth breathing:
  • Place your tongue behind your front teeth on the roof of your mouth
  • let your tongue fill the space between the upper molars
  • gently suck to form a light vacuum
Practising during the day can help you to keep it at night

هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه هههههه
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#9
(04-09-2015, 03:47 PM)DariaVader Wrote: Current Policy Statement
Health Net, Inc. considers adaptive servo-ventilation for the treatment of central or complex sleep apnea investigational due to insufficient evidence in the peer review published literature demonstrating its long- term safety and efficacy.


yeah, laughable, especially as they go on to explain the recommendations to the opposite effect

Exactly. Their citations support the opposite conclusion.
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#10
While reading that policy statement, I was beginning to think that I was loonier than normal. Glad to hear that others got the same thing out of it that I did.
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