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When Medicare doesn't pay
#1
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...
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#2
Oddly, the benefits report from my secondary insurance does show a charge for the CPAP machine!
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#3
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.

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#4
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.
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#5
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...
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#6
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.

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#7
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.
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#8
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.




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#9
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.
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#10
Yes, it does have the footnote about "you did not know".
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