Insurance Denied Coverage for Medical Equipment

[Anonymous]

You need to appeal. There is a process. Look at insurance company website. The docs likely have to do additional paperwork.

[Anonymous]

She should receive a written denial letter in the mail that will explain why it was denied and the appeal process. There may be a way for her doctor to call in for a Peer to Peer review to reverse the decision.
Mid the results of the sleep study weren’t submitted with the request, that could explain why it was denied.

Tell your mom not to throw away any letters from the insurance company/ Medicare.

Is she on a Medicare Advantage plan?

[Anonymous]

Follow through with all the processes and keep documentation, and take it to Social Media. People need to underStand what happens. Write your senators and congress critters and encourage others to do the same

[Anonymous]

Get a prescription including required settings.

Look online.

Pick a machine and mask combo.

Submit the prescription with your order.

Charge to your or her credit card.

[Anonymous]

Medicare should cover a CPAP machine, no questions. They do have more requirements for the BiPAP machine.

In order for you to talk to Medicare on your mom’s behalf, you either have to sit with her on the phone or she has to fill out an authorization form, allowing you to be her designated representative to talk to them. They won’t talk to you otherwise.

You could also call her doctors office ask them what durable medical equipment supplier (DME) they sent the prescription to. Then call them and ask if they called your mom. They’d be the most likely people to call her. They are the ones who would have contacted Medicare to see if they would pay for the device.

The cost of a bipap machine is about $1500, with Medicare your mom would have to pay 20% of that.

[Anonymous]

Not sure how recent this is but it’ll help you understand Medicare language

https://cdn.websites.hibu.com/a671338f9505496fb6076f9746e6ab9d/files/uploaded/oxymed_medicare_cpap_bipap_coverage_criteria.pdf

[Anonymous]

Anonymous wrote:

Anonymous wrote:Not Medicare-specific, but hrowing out some ideas of things I'd try:

Could you buy it outright without insurance? They might not want to rent to you because an individual might stop paying.

Log into/ call her insurance and push for the exact reason for denial, the diagnosis codes, they think she has according to the paperwork they have, what diagnoses (if any) would get it covered, what does she have to try first (if anything). Push nicely but firmly, ask for supervisors, etc. I rarely get a straight answer the first time anything is denied and way more often than should be the case, there's some issues on someone else's side.

Might be a paperwork thing. So many times we've needed authorization or a doctor's notes for things, it takes iterations.

Did your mom try to order from an approved DME vendor. They might only cover McKesson or whatever and not the company the doctor sent her to.

Call the doctor. Are you sure the one he prescribed is better than the one(s) she can get with insurance? (Don't do this until you figure out why it was denied. Could be other logistics.)

Thank you! Frankly mom shouldn't be talking to anyone about this stuff. She's so easily confused (no surprise since she's literally getting less than half the air she needs with each breath). She thinks they denied the BIPAP entirely, not just a certain type. Will call and find out the exact reason for the denial and what info insurance has.

In general, insurance is also required to put a denial in writing. They will call first sometimes (IME), but documentation is required. So your mom should be getting communications from the insurance company in the mail or possibly electronically/via email or portal. If you are going to be helping to manage her care I'd figure out how to set up an online account and then you can monitor it for her.

[Anonymous]

Medicare will not be denying coverage of CPAP assuming your mom's doctor prescribed it correctly after she met their requirements for it.

Medicare might require her to do 3 months of CPAP and "fail" before authorizing the BiPAP also called RAD.

Her doctors though should know all of this.

[Anonymous]

If you mom has a Medicare Advantage plan instead of Regular Medicare, they still should be covering a CPAP machine. Or a BiPap machine if she tried the CPAP machine and failed.

But they could make it more difficult. You may need to jump through more hoops, get more prior authorizations, etc. Medicare Advantage plans stink.

https://www.medicare.gov/publications/11045-medicare-coverage-of-dme-and-other-devices.pdf

What if I need DME, and I’m in a Medicare Advantage Plan?

Medicare Advantage Plans must cover the same medically necessary categories of
DME items as Original Medicare (Part A and Part B). However, the suppliers you get
your DME from and your specific costs will depend on which Medicare Advantage
Plan you belong to.

If you’re in a Medicare Advantage Plan and you need DME, contact your plan to find
out if it will cover the DME. If your Medicare Advantage Plan won’t cover a DME item
or service that you believe you need, you can appeal your Medicare Advantage Plan’s
denial of coverage and get an independent review of your request for coverage.
You can also find a description of your Medicare Advantage Plan cost-sharing for all
Medicare covered services, including supplemental benefits offered by your Medicare
Advantage Plan, in its “Evidence of Coverage” document

[Anonymous]

Welcome to the world in which so many of us understand why Luigi did what he did. While caring for my dad in his last two years, I spent approximately 10 hours a week dealing with insurance and billing problems...denials, double billing, denials, denials, denials. They wear you down to a nub.