Medicare Same & Similar Updates

By Lesia Crawford for the November 2018 DSM Insider

As promised, here’s the highly anticipated follow up to the Panic at the Medicare Disco article regarding Medicare Same and Similar denials. We’ve learned a lot in the meanwhile, & I want to share some important updates with you.

To recap, in March Medicare imposed an update to their system and code E0486 (Oral Appliance) has been triggered on the same and similar list. Jurisdictions A and D have implemented the change and as of today B and C have not yet done so.

So, what does this mean, you ask? Great question. It means that if the patient has had Medicare benefits for treatment of sleep apnea with a PAP machine within 5 years, the claim for the oral appliance will be denied. One exception to this rule is when the patient stops treatment before the end of the three month trial, and their treating MD does not submit the 90 day CPAP recertification letter. Not submitting the letter causes Medicare reimbursement for CPAP to stop. Any patient who keeps their CPAP past the 90 day trial will have a denied claim and the only option for payment is through the reconsideration process and/or appeal. A successful appeal needs to meet the Medicare guidelines for Medical Necessity and give a “compelling reason” why the patient stopped PAP therapy and an appliance was ordered by the treating MD. In addition to the medical records, the RX/LOMN for the oral appliance also needs to be submitted with the documents. Acceptable reasons for the switch in therapy include:

Non-compliance: The patient is using the PAP less than the required amount of time considered compliant.  Patients are not compliant unless they use the machine at least 4 hours each night for 70% of the nights. The reason for non-compliance must be documented

Intolerance: The patient can’t tolerate the machine, mask, tubing, straps on their face, noise, etc. The list on the intolerance forms help the patient describe the reasons for intolerance. By itself, the intolerance affidavit will not be accepted. Your patient must have a discussion with their treating Medicare MD or PA. Request the clinical notes from the face to face consult, notate the review of the records in the consult and/or exam visit notes.

Treatment failure: This explains that PAP did not effectively treat the OSA. It should be documented with a follow-up sleep study along with subjective results. This may also be the reason for dual therapy. For example, the patient has an AHI of 72 and PAP brings them down to a 20, but they’re still symptomatic. Rationale for dual therapy does not include inconvenience, like taking the PAP on the plane for a trip to Boca. Medicare does not pay for a second therapy for travel. If you can afford to go on vacation, you can pay for your appliance.

PAP therapy was contraindicated: Reasons include if they cannot fall asleep and/or awaken during the night because of the PAP, their quality of sleep or AHI is worse with the PAP than with nothing.

We’ve had tremendous success with reconsiderations and appeals which means the claims have ultimately paid. Just a few examples where we’ve seen success:

• Claims with complete case files including documentation from the ordering physician’s instructions to cease CPAP and ordering an appliance.  
• Dual therapy for an implant denture patient whose bite would collapse without the appliance.
• CPAP being returned within the 90 days have also paid without being denied as anticipated.

Denials that have not been overturned have been missing one or more critical pieces of documentation or it was obvious that the device was for travel or convenience. I asked you all not to panic, to have faith in Medicare reviewing each appeal and covering the services needed, and I’m thrilled to confidently report that there is no need to panic.   

Did you know there are two different ABN forms? One for accepting assignment and one if you do not accept the assignment. Please email me if you would like me to send them to you as well as a check list from the AADSM for your patients who have used CPAP. Lesia@gogobilling.com