Anonymous wrote:She may need a sleep study to get one.

She had one just last week so the results wouldn't have been sent anywhere yet, but yes, I wondered about that too. The tech said her oxygen levels were really low all night, so maybe that will help.

Anonymous wrote:Has your mom been voting for Republicans?

Uggg...

She may need a sleep study to get one.

Has your mom been voting for Republicans?

https://med.noridianmedicare.com/web/jddme/topics/ra/denial-resolution

Common denial issues

Anonymous wrote:Insurance can deny because the plan doesn’t provide coverage for what has been requested or because they found it was not reasonable or necessary. If coverage doesn’t exist, you’re out of luck. If you don’t buy the coverage for something the carrier has no obligation to pay for it.

If the issue is reasonableness and necessity the question then is what information did the party who looked into coverage provide. Was it complete and on point. And the question is why did the carrier find it wasn’t reasonable or necessary. Once you know these things you can figure out how to proceed.

Thank you. This is a helpful categorization of the potential issues.

Anonymous wrote:Also I'm pretty sure Medicare covers BiPAP machines if medically necessary and a Medicare Advantage plan or Medigap plan has to cover everything Medicare covers. (Maybe not necessarily the exact brand the doctor prefers)

So you can call 1-800-Medicare and figure out how they define medically necessary and what the plan can ask for to prove it.

Thank you for the phone number. Yeah, I thought a BIPAP wasn't super unique.

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.

My sister, who was on Medicare, had an oxygen machine and a hospital bed prescription from the hospital when she was released. There was a monthly rental fee for these items. Sorry, I do not remember how much $$ or if Medicare subsidized some of the cost.

Also I'm pretty sure Medicare covers BiPAP machines if medically necessary and a Medicare Advantage plan or Medigap plan has to cover everything Medicare covers. (Maybe not necessarily the exact brand the doctor prefers)

So you can call 1-800-Medicare and figure out how they define medically necessary and what the plan can ask for to prove it.

I got an extra comma in there somehow. I mean ask for the diagnoses they have in their paperwork, then you can ask the doctor if that's consistent with why the doctor prescribed it to determine if the insurance company is missing some important information.

Insurance can deny because the plan doesn’t provide coverage for what has been requested or because they found it was not reasonable or necessary. If coverage doesn’t exist, you’re out of luck. If you don’t buy the coverage for something the carrier has no obligation to pay for it.

If the issue is reasonableness and necessity the question then is what information did the party who looked into coverage provide. Was it complete and on point. And the question is why did the carrier find it wasn’t reasonable or necessary. Once you know these things you can figure out how to proceed.

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.)

Call the insurance company.

If anyone has advice on how to proceed, I would appreciate it.

My mom's neurologist and pulmonologist both recommended a BIPAP. With each breath my mom is only getting 40% of the volume of air that she needs to be getting. Someone, my mom is confused as to who, called my mom yesterday and told her the insurance company denied the request for a BIPAP. She didn't understand anything else that they said.

I think the first stop is to figure out who called my mom and get more details from them.

If the insurance company really did deny the claim, I'm a bit at a loss as to how they could do that. Obviously I need to understand my mom's insurance plan better. She has what she thought was "the good" Medicare plan. Her specialists said she needs this machine to breath better. How could this be denied?

FWIW I did look into her just renting the machine herself so she wouldn't have to wait for insurance to review and approve the request. The company I called said they would only rent that to someone who had been approved by insurance, so basically we can't get what my mom's doctor's prescribed without insurance's approval, even if she were willing/able to pay for it completely herself. This seems crazy! (Yes, I am relatively new to elder care issues).

Thank you for any insights or suggestions.