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Medicare Denial
#31
Thank You Sleeprider. That is much more info than I found on Google. So much helpful info in two short paragraphs. Who should I ask to request a copy of the sleep study? The DX should be no problem. I'm sure U.S. Medicare will require some hoop jumping but my insurance picks everything Medicare approves but doesn't pay. I'll look into ASV bilevel machines but ultimately the Doctors , DME & Medicare will pick it out.

Thanks Again
Your Friend Kidnap
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#32
(09-14-2015, 07:33 PM)Kidnap Wrote: I am a newbe. I don't even have my cpap yet.

Last September I had a total hip replacement on my left hip. In October I had my annual physical exam. My Hematocrit (HCT) count was 52.2 which cound indicate sleep apnea. He wanted me to take a sleep study but due to hip problems I put it off until August. The test showed AHI of 53 and SpO2 at 70%. Medicare first said I could get a AirSense™ 10 AutoSet CPAP, BUT then denied me because I didn't see my Doctor "Face to Face" within 6 months. They now want me to take the Sleep Study and titration test over. I would then probably have to pay for the first two tests out of pocket because a bureaucrat says they can't be used because of a 6 month rule. Some people say my family doctor isn't good enough I must see a Pulmonary Doctor "Face to Face" .

Has anyone else had this problem or how to get around it?

Yes, Medicare has an appeal process. You can get around a lot of these time constraints when you can present your case and it involves other medical issues.
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#33
Thanks Mosquitobait,

I'll keep this in mind if I get rejected this time. For now I'll let it run it's course. I'm waiting for the pulmonologist to make a decision. Maybe I'll have to see him, or spend an other night in sleep lab concentration on the complex apnea. or maybe just order a cpap of some kind.

Thanks again
Your Friend Kidnap
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#34
You can ask for a copy of the sleep study through either your doctor, or directly from the sleep center. As you know, we are entitled to any medical record, report, prescription by HIPPA. A good summary of your rights is summarized here: http://www.hhs.gov/answers/health-care/w...index.html Anyway, these records have importance that may outlive your relationship with your current doctor and the sleep center. I just used my sleep study records from 2008 to obtain insurance authorization this past February. Imagine the difficulty trying to track these down 5 to 10 years from now, if you don't keep them now.
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#35
Wow! I never considered the possibilities. Thanks a Million!
Your Friend Kidnap
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#36
I have the sleep study & titration study out of the way by Oct. 5th . I waited until Oct. 10 and called the Sleep Lab. to see which doctor the info was sent to to evaluate my CPAP requirements. He said it was the Pulmonary Associates. He then found their report and it was to get a AirSense 10 AutoSet with settings at 7 & 20. They would evaluate my progress to see if I need additional sleep study or go to AirCurve 10 VAuto or ASV. Gotta be the cheapest way out for U.S. Medicare. Anyway I called the DME & was told that they would get back to me. It took a day but they called and asked me for proof I saw my Doctor Face-to-Face. The doctor would have to fax the info to them. I called my Doctors office & had them fax the info., I called back on Friday morning & was assured that it was faxed but they would re-fax just in case it got lost. Still waiting. PS how's come they found out I didn't see him face-to-face last year but not that i did see him this year. Hmmmm ? ?
Your Friend Kidnap
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#37
Kidnap, I don't know what DME you are working with, but I'm going to plug Remworks at the Waterfront for those of us in Pittsburgh area. They have been very helpful getting me the machine I wanted, even though it's not what insurance though I should have. Nice store, and you can always stop at Rock Bottom for lunch and a beer.
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#38
Kidnap

I wonder if the DME is looking at the old records. As I understand it, the face to face is required after you have used the CPAP device and demonstrated you were compliant with using it.

I believe the process is this:

.. evidence via sleep test/titration that CPAP therapy might be beneficial.

.. Next you get a machine and demonstrate you will actually use it (i.e. Compliance).

.. Then comes a required face to face at which the doctor reviews your data to establish that you are compliant AND that the therapy is effective for you.

So in the new cycle you just started it is out of place to require a face to face before you get a machine. All it should require is a test report and a prescription.

Is the DME aware that you are starting over? Could they be thinking about the last time you did all this and they don't have the new data?

HTH

Saldus Miegas

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#39
For Sleeprider, If Allegheny Health Systems (formerly Klingensmith Health Systems doesn't soon contact me I'll call them and if I get more static I'll try Remworks.

For Saldus Miegas, For U.S. Medicare First you need a Face-to-Face, he then writes a script for the sleep study. You have to get the study within 6 months. (I guess they think you could recover on your own? ? ? ) after that you are correct on the remaining hoops to jump through.

Thanks Guys.
Your Friend Kidnap
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#40
FYI, Remworks is a division of Highmark. I'm pretty sure you'd like them. They ship most things to you, so you don't have to go to the storefront, but it's nice to meet with people if you want. What impressed me was their willingness to take my input, and work with the doctor and insurance to make it happen. I didn't so much have to push them, they took initiative and got the approvals as though I was important to them and they wanted the sale. Best part is, it didn't cost me anything. I have Aetna insurance, and it's not the easiest to deal with, so I appreciated what they did to get the machine of my choice.
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