DME refusing to bill Aetna

[hatanipai]

I was diagnosed with OSA in April, and was setup on my CPAP shortly thereafter. When I recently called for supplies I was told by my DME that my file was on hold. After looking into the issue further the DME told me they had not submitted the claim to Aetna, and will not submit the claim, because according to their interpretation of my sleep study I do not qualify for CPAP therapy (notwithstanding the Rx from my sleep doctor). They said they should not have set me up with the machine in the first place. The DME is saying Aetna goes by the Medicare criteria, which I apparently do not meet.

My sleep study records indicate an "AASM Apnea/Hypopnea Index (AHI)" of 19.6 (dropped to 1.5 with CPAP), and "AHI per Medicare criteria" of 1.9 (dropped to 0.7 with CPAP). The DME is focused on the 1.9, and says Aetna will reject the claim unless that number exceeds 5.0.

My provider is saying I do qualify for CPAP, and that Aetna would not apply Medicare criteria to me because I am 36 years old. The DME is nonetheless refusing to submit the claim, saying they are concerned they will be viewed as submitting a fraudulent claim.

Any thoughts? Has anyone else run into this issue?

[retired_guy]

1. Call your sleep doc and report this problem.

2. Ask for a referral to a different DME.

3. Failing in that, ask for a copy of your prescription, then visit one of our quality suppliers listed at apneaboard.com for help.

5. Once you get all this taken care of, tell your original DME to kiss ---- nah, that wouldn't be nice.

[bwexler]

Call Aetna. Ask them exactly how they would treat your claim. Get their response in writing. If it is positive send a copy to the DME and tell them to submit the claim. If Aetna says NO, go back to square one and decide what you are willing and able to pay and go shopping on line.

Or, you can appeal to Aetna until you convince them to pay.

You might want to post your actual sleep study complete report (minus personal data) here. Your description does not exactly make sense to me. The experts here may be able to enlighten us.

[trish6hundred]

Hi hatanipai,
WELCOME! to the forum.!
Call your doc and let him/her know about the problems you are having.
I'm sorry you are going through this, just keep on going,'till you get this straightened out and hang in there for more suggestions.
Best of luck to you.

[zonk]

From http://www.resmed.com/content/dam/resmed...3493r6.pdf: Key Coverage Criteria Required for All CPAP Claims

A single-level CPAP device (E0601) is covered for the treatment of OSA if criteria A-C are met:

A. The patient has face-to-face clinical evaluation by treating physician prior to the sleep test to assess the patient for OSA.
NOTE: Physicians shall document the face-to-face evaluation and re-evaluation in a detailed narrative note in their charts. For the initial evaluation, the report would commonly document pertinent information (ie, history and physical exam), but may include other details.

B. The patient has a Medicare-covered sleep test that meets either of the following criteria:

1. The apnea–hypopnea index (AHI) or respiratory disturbance index (RDI)* is ≥ 15 events per hour with minimum of 30 events; or

2. The AHI or RDI is ≥ 5 and ≤ 14 events per hour with minimum of 10 events and documentation of:

a. Excessive daytime sleepiness, impaired cognition,
mood disorders or insomnia; or

b. Hypertension, ischemic heart disease or history of stroke

C. The patient and/or their caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment.

* The RDI is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure (PAP) device.

[hatanipai]

Thanks for the responses. I should clarify that I have talked to my sleep dr's office--they are the provider I mentioned in my initial post who said I do qualify for CPAP, and that Aetna would not apply Medicare criteria to me because I am 36 years old. They say they called Aetna and confirmed, but the DME is still refusing to submit the claim. I may end up switching DMEs, but hesitate to do so if what they are saying is right--that I don't meet Aetna's requirements.

It doesn't look like my attachment size quota is large enough to post my actual test results. To summarize, they recorded 41 events--all hypopnea, 37 of which are described as AASM hypopneas and 4 of which are described as Medicare hypopneas. All 41 were recorded as "arousals" and there are 0 events described as ">3% desaturation". I am still struggling to understand the difference between the AASM and Medicare scoring, and especially why according to the Medicare criteria I would not need therapy even though my AASM events were 37 and AASM AHI was 19.6.

[justMongo]

You can push your scanned documents up to a free photo sharing website such as photobucket.com
You put the images inline for your post with the html [img] tag. The http link goes between tags. end with a /img in brackets.
I'd write an example --- but it would interpret it as an image.

I don't know why age 36 would mean Medicare criteria would not apply. (We are talking US Medicare? Other countries also use the word Medicare.)
There are 36 year old people who are disabled and therefore qualify for Medicare. I think age is not a factor.

A letter of need from your doctor might sway Aetna. Else, pack up what they gave you and throw it at them give it back.
And, tell them what retired_guy suggested.

Look at the supplier list -- you can get what you need with your doc's Rx. You might even get a price from a supplier on the list and tell your current DME if they'll match it, you'll buy from them.

[bwexler]

Until YOU talk directly with Aetna you will not know what they will or will not do.
Once they tell you what they will do get it in writing.
Then you will have a place to begin.

[PaytonA]

bwexler is right. When Aetna tells you something, get it in writing. They are well known for telling you one thing and having it turn out differently. I am not sure how knowledgeable their first line customer support people are.

Best Regards,

PaytonA