Medicare Service Refusal

[Gsbowers]

My sleep doc finally found a device which controls my apnea. But now Medicare claims my ResMed Aircurve 10 ST is not approved for treating sleep apnea and will not pay for device or any sleep Apenea supplies or medical support. Anyone ever run into this, what did you do?

[Mike1953]

As you were told in the other forum it is covered. Your Dr. and DME or supplier must follow the Medicare paperwork completely or they will deny any and all payment. It is just that simple! Some where in the chain of paper trail something was not completed or worded to Medicare requirements.

[justMongo]

As you were told in the other forum it is covered. Your Dr. and DME or supplier must follow the Medicare paperwork completely or they will deny any and all payment. It is just that simple! Some where in the chain of paper trail something was not completed or worded to Medicare requirements.

First, permit me to ask if you are in the USA? (Other countries have an NHS program called Medicare.) If in the USA, then you are being lied to.

Since Medicare only pays about a dime on a dollar, it would appear your provider is trying to get you to pay full price for everything. Take you prescription to another supplier.

[trish6hundred]

Hi Gsbowers,
WELCOME! to the forum.!
Hang in there for more responses to your post and much success to you in getting your insurance problem straightened out and with your CPAP therapy.

[Jim Bronson]

Refer them to the "Medicare & You 2016" manual, page 50. Ask them why it doesn't apply to you like it does for every other Medicare recipient.

[Mike1953]

Refer them to the "Medicare & You 2016" manual, page 50. Ask them why it doesn't apply to you like it does for every other Medicare recipient.

Continuous Positive Airway Pressure (CPAP)
therapy
Medicare covers a 3-month trial of CPAP therapy if you’ve been
diagnosed with obstructive sleep apnea. Medicare may cover it
longer if you meet in person with your doctor, and your doctor
documents in your medical record that the CPAP therapy is
helping you.
You pay 20% of the Medicare-approved amount for rental of the
machine and purchase of related supplies (like masks and tubing),
and the Part B deductible applies. Medicare pays the supplier to
rent the machine for 13 months if you’ve been using it without
interruption. After you’ve rented the machine for 13 months, you
own it. Note: If you had a CPAP machine before you got Medicare,
Medicare may cover rental or a replacement CPAP machine and/or
CPAP accessories if you meet certain requirements.
If you live in certain areas of the country, you may have to use
specific suppliers for Medicare to pay for a CPAP machine and/or
accessories. See page 53 for more information

[DariaVader]

Mike1953, that is the CPAP criteria. There are different ones for ASV

[Mike1953]

Mike1953, that is the CPAP criteria. There are different ones for ASV

Sleep apnea & Continuous Positive Airway Pressure (CPAP) devices & accessories

How often is it covered?

Medicare covers a 3-month trial of CPAP therapy if you’ve been diagnosed with obstructive sleep apnea.

Medicare may cover it longer if you meet in person with your doctor, and your doctor documents in your medical record that the CPAP therapy is helping you.

Note
If you had a CPAP machine before you got Medicare, Medicare may cover rental or a replacement CPAP machine and/or CPAP accessories if you meet certain requirements.
Note
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
Who's eligible?

People with Medicare Part B (Medical Insurance) who’ve been diagnosed with obstructive sleep apnea.

Your costs in Original Medicare

You pay 20% of the Medicare-approved amount for rental of the machine and purchase of related supplies (like masks and tubing). The Part B deductible applies.

Medicare pays the supplier to rent the machine for the 13 months if you’ve been using it without interruption. After you’ve rented the machine for 13 months, you own it.

Medicare will only cover your durable medical equipment (DME) if your doctor or supplier is enrolled in Medicare. If a DME supplier doesn't accept assignment, Medicare doesn't limit how much the supplier can charge you. You may also have to pay the entire bill (your share and Medicare's share) at the time you get the DME.

Competitive Bidding Program

If you live in or visit certain areas, you may be affected by Medicare's Competitive Bidding Program. In most cases, if you have Original Medicare and get competitively bid equipment and supplies in competitive bidding areas, Medicare will only help pay for these equipment and supplies if they're provided by contract suppliers. Contract suppliers can't charge you more than the 20% coinsurance and any unmet yearly deductible for any equipment or supplies included in the Competitive Bidding Program.

Note
If your current supplier doesn’t get a new contract, you may still be able to stay with that supplier if they decide to participate in the program as a “grandfathered” supplier. Suppliers that don’t get Medicare contracts can decide to become "grandfathered" suppliers. This means a supplier may continue to rent equipment to you if you were renting the equipment when the program started. This rule applies to oxygen, oxygen equipment, and certain rented equipment. You may continue using the “grandfathered” supplier until the rental period for your equipment ends.
If you start renting additional equipment from a “grandfathered” supplier after the program starts, Medicare won’t pay for the new equipment.
If you’re renting equipment that’s eligible for grandfathering, your supplier will let you know in writing 30 business days before the program begins whether it will or won’t become a “grandfathered” supplier.
What happens if my supplier decides not to become a grandfathered supplier?

You need to decide whether to continue to rent from your current supplier and pay all the costs, or switch to a Medicare contract supplier.
A supplier that doesn’t have a new contract and decides not to become a grandfathered supplier is required to notify you and pick up the item from your home after the program starts. Your supplier must notify you these 3 ways before it can pick up the item:
The supplier must send you a letter at least 30 business days before the program starts telling you that it will no longer provide rental items to you after a certain date. This letter will tell you the date that a Medicare contract supplier must start to provide you with the rented item.
The supplier must call you 10 days before picking up the item to make arrangements for pick up at an agreed upon time.
The supplier must call you again 2 business days before picking up the item.
A supplier that isn’t grandfathered can't pick up a medically necessary item before the end of the last rental month for which the supplier is eligible to get a rental payment, even if the end of the last rental month occurs on or after January 1, 2014.
If you change to a Medicare contract supplier, your old supplier should work with the contract supplier so there isn’t a break in service. Keep the pickup slip or other documentation from the supplier that shows you no longer have the item.
Under current Medicare rules, you own these types of equipment after renting for 13 months. When you switch to a Medicare contract supplier instead of using a "grandfathered" supplier or other non-contract supplier, your 13-month rental period will start over, so you won't own the equipment until after the new rental period ends. This will extend your rental period and result in additional months of coinsurance. However, the amount you pay may be lower because the amount you'll pay will be based on the new payment rates under the new program.

Once you own the equipment, you must get replacement supplies and accessories for the equipment from a contract supplier in order for Medicare to help you pay for these items. You may get repairs for the equipment you own from any Medicare-approved supplier (even a non-contract supplier), including replacement parts needed for the repair.
If you already own your equipment, you must use a Medicare contract supplier for your replacement supplies and accessories.
Find a Medicare contract supplier.

Note
To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service.

[DariaVader]

not sure what your point is. that is still the coverage for cpap rather than asv.

[Mike1953]

not sure what your point is. that is still the coverage for cpap rather than asv.

It is the same. https://www.cms.gov/Outreach-and-Educat ... 905064.pdf