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insurance advice for denied CPAP claims
I have a similar problem with Medicare denying my CPAP machine. At first they approved the machine, put me on a rent-to-own-in-13-months plan and then... and then!! Did an "audit" and denied my machine and any replacements (mask, filters, hose, etc.) because my sleep doctor did not see me (physically) before he ordered my machine. Here's what happened:

Had an initial sleep test at the local hospital (90 miles from home - and I do not drive because of my eyesight). Turns out that test was improperly done and my primary physician sent me home with another overnight pulse oximeter test. When I saw my doctor again he said he was certain I had sleep apnea and had his nurse make an appointment for another sleep test with a "real" sleep doctor (150 miles away in a "real" city - the closest "real" sleep clinic to where I live). He FAXed my initial sleep study report to the sleep doctor along with other data from the oximeter and my cardiologist (who is located 255 miles away from home).

The next day the sleep doctor calls me, asks questions based on what my cardiologist and primary physician have observed and documented and decides to order a CPAP machine for me and wants me to "get used to it" before the sleep test he has scheduled for me two weeks later. So, I go back 90 miles the next day and get my machine from the DME at the local drug store in the small town where my primary physician practices medicine. The sleep doctor has FAXed the prescription to the DME. I put the machine on the first night and - sleep 9.1 hours without waking up! A miracle cure as far as I'm concerned.

I feel my sleep doctor was only trying to be practical considering the distances I need to travel. My DME had no idea the sleep doctor had prescribed my machine without seeing me. I had no idea Medicare would deny my claim, but here's the "weird" part: Medicare says I do not have to pay for the machine because I did not know Medicare would not cover the machine's cost. I get to keep the machine, I guess. I've had it since last October. My DME keeps giving me masks and filters even though Medicare won't pay and they don't ask me to pay (so far). So, I'm pretty conflicted.

What to do?
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I'm in the appeals process now and need to send them a letter. Apparently after I had called to set up the authorization, I was then supposed to send them my claim documents and prescription for final approval. Since the authorization was never finalized, it was rejected. Why they can't "approve" it when they get the claim form is beyond me, since my prescription and diagnosis were attached. What's the point of sending the same documents twice?

Anyway, want to hear something funny? They did approve my mask/headgear, the hose, and the humidifier. They only rejected the APAP, but all of these things were part of the same claim and pertaining to the same authorization!Oh-jeez
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Truth is stranger than fiction, because fiction has to make sense.
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(08-27-2013, 05:31 PM)RonWessels Wrote: Truth is stranger than fiction, because fiction has to make sense.

I got the formal denial letter in the mail yesterday (meantime the appeal is still being processed) and the letter kind of made me upset. It was from the medical director at the insurance company, an M.D., and he concluded that my CPAP wasn't medically necessary. Apparently they require a measured AHI of 15 or above, or a secondary condition (hypertension was mentioned as one of them) in addition to the sleep apnea. He also mentioned that because they rent CPAP machines on a 13-month program, that precludes me from seeking reimbursement for equipment purchased on my own.

First, he obviously didn't look into my medical record. I do have hypertension and they are paying for a portion of my hypertension meds! They have been for a while. I disclosed it to them when I signed up. It's also mentioned in my medical record and on my sleep doc's patient notes. I can't believe an M.D. would give someone with a positive diagnosis of OSA the advice that a CPAP isn't medically necessary. I don't care who he works for... that's unethical in my book.

Second, he didn't bother investigating the authorization. If he had spoken to the person that set it up for me, he would have maybe been made aware that I had explained the situation to them and they agreed to let me file the claim.

Now I have to try to retroactively add that information to the appeal letter, lest they deny it again.

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those that are dealing with medicare, the deductibles and coverage is not so good. See if you can get supplemental insurance or an insurance policy that replaces medicare. I am too young for a supplemental insurance policy but I have an insurance policy that replaces medicare and I have NO deductibles, no copays (unless I go out of network) and so far it has been great. I do have to pay additional premiums for it over and above the medicare premium but it also includes prescription coverage at a reduced rate due to my income. Hope this helps you. Sorry for what you are all going through.
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