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When Medicare doesn't pay
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Sn00zeAlarm Offline

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Machine: Resmed A10 autoset
Mask Type: Nasal pillows
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Humidifier: Builtin
CPAP Pressure: 5-7
CPAP Software: SleepyHead

Other Comments: Heated hose

Sex: Male
Location: Florida US

Post: #1
When Medicare doesn't pay
I just received my Medicare Summary Notice (Part B) for the last 3 months, and they denied coverage for the Sleep Study. ($1420) The reason given is the usual "The information provided does not support the need for this item", along with a reference to "Policy L33405". This is the Local Coverage Determination for Polysomnography. Of course, the Medicare Summary does not tell you exactly which part of that is the relevant one. Does anyone have suggestion for what the usual problem is here?

I found it odd that the same Medicare Summary does not mention payments for the CPAP machine itself, which I received about 3 months ago! Surely the DME has billed for that by now...
07-21-2016 03:15 PM
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Sn00zeAlarm Offline

Preferred Members

Posts: 72
Joined: May 2015

Machine: Resmed A10 autoset
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
Humidifier: Builtin
CPAP Pressure: 5-7
CPAP Software: SleepyHead

Other Comments: Heated hose

Sex: Male
Location: Florida US

Post: #2
RE: When Medicare doesn't pay
Oddly, the benefits report from my secondary insurance does show a charge for the CPAP machine!
07-21-2016 03:21 PM
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OpalRose Offline

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Machine: PR System One REMstar Auto 560 with A Flex
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CPAP Software: SleepyHead EncoreBasic

Other Comments: Started CPAP Therapy October 23, 2014

Sex: Female
Location: Northeast Ohio, USA

Post: #3
RE: When Medicare doesn't pay
It may be that the Doctor or Sleep Center did not fill out the paperwork properly. I also have noticed that Medicare loves to deny coverage, then wait to see if you will appeal.
You will need to call Medicare and find out exactly what documentation they want. Then call your doctor or sleep center and ask them to resubmit with corrected information.

OpalRose
07-21-2016 03:32 PM
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justMongo Offline

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Machine: ResMed VPAP Auto (S9)
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Other Comments: μολὼν λαβέ

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Location: Калифорния

Post: #4
RE: When Medicare doesn't pay
Tagged. I'd like to know the answer to this.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
07-21-2016 03:36 PM
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Sn00zeAlarm Offline

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Posts: 72
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Machine: Resmed A10 autoset
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
Humidifier: Builtin
CPAP Pressure: 5-7
CPAP Software: SleepyHead

Other Comments: Heated hose

Sex: Male
Location: Florida US

Post: #5
RE: When Medicare doesn't pay
I have never gotten anyone at Medicare to tell me "what information would make you approve this claim". The people who answer the phone do not have that sort of information. The decisions are actually made by a subcontractor for my area. All appeals must be in writing, within 120 days. The web site for the contractor does not even have any contact information for patients, and they do not consider the patient to be their customer - their customer is the US Government.

Hopefully somebody at the doctor's office knows how to figure this out - they must run into it all the time. I will drop in on the office tomorrow...
07-21-2016 03:39 PM
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OpalRose Offline

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Posts: 3,181
Joined: Nov 2014

Machine: PR System One REMstar Auto 560 with A Flex
Mask Type: Nasal pillows
Mask Make & Model: AirFit P10 For Her
Humidifier: REMStar heated humidifier with heated hose
CPAP Pressure: Auto Cpap 10-13 AFLEX 1
CPAP Software: SleepyHead EncoreBasic

Other Comments: Started CPAP Therapy October 23, 2014

Sex: Female
Location: Northeast Ohio, USA

Post: #6
RE: When Medicare doesn't pay
Yes, please let us know what you find out.

Ironically, I received a letter yesterday from my DME saying that my insurance may ask me to choose a different DME.
Very short letter, with no further explanation as to why. So I guess I find out when they deny payment.

OpalRose
07-21-2016 04:05 PM
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justMongo Offline

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Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
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CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #7
RE: When Medicare doesn't pay
CMS is a subcontractor to the US government. Just like an aerospace contractor.
You cannot sue Medicare -- but, the umbrella protection does not extend to CMS -- they can be sued.

I appealed when CMS cut my DM testing from 5X to 3X. I wrote a darn good appeal -- they denied it.
Some on the people at CMS belong in prison.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
07-21-2016 04:06 PM
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PaulaO2 Offline
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Other Comments: Ehlers-Danlos Syndrome, Hypermobility Type; chronic sarcasm

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Location: western NC, USA

Post: #8
RE: When Medicare doesn't pay
Let the doc office handle the filing. That is what they do. By the time you get the denial, they've probably already refiled it. You can contact and ask to speak to someone in billing or whoever deals with Medicare.

Even then, they may have to swallow the cost unless you signed a form saying you would pay for it if denied. This is why everything is so expensive. They charge so much so that those that pay cover those who cannot/do not.

PaulaO2
Apnea Board Moderator
www.ApneaBoard.com


Breathe deeply and count to zen.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
07-21-2016 04:30 PM
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justMongo Offline

Monitors

Posts: 3,853
Joined: Sep 2013

Machine: ResMed VPAP Auto (S9)
Mask Type: Full face mask
Mask Make & Model: ResMed Mirage Quattro
Humidifier: ResMed H5i
CPAP Pressure: 18 IPAPmax - 11 EPAPmin, PS=5
CPAP Software: Other Software

Other Comments: μολὼν λαβέ

Sex: Male
Location: Калифорния

Post: #9
RE: When Medicare doesn't pay
Yes, as Paula says. Plus check for footnotes on the MSNs from CMS. Some footnotes say they won't pay; but you cannot be billed because you didn't know.

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
07-21-2016 04:58 PM
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Sn00zeAlarm Offline

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Posts: 72
Joined: May 2015

Machine: Resmed A10 autoset
Mask Type: Nasal pillows
Mask Make & Model: Resmed P10
Humidifier: Builtin
CPAP Pressure: 5-7
CPAP Software: SleepyHead

Other Comments: Heated hose

Sex: Male
Location: Florida US

Post: #10
RE: When Medicare doesn't pay
Yes, it does have the footnote about "you did not know".
07-21-2016 05:16 PM
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