Wednesday, September 25, 2013

Quality Care

I am constantly reminded how fortunate I am to have Mom watching out for my sister's best interests.

Yesterday, Mom received an explanation of benefits (EOB) from Medicare which shows the use of the oxygen condenser has been denied coverage for Lyn.  Medicare has deemed the equipment to not be medically necessary for Lyn because she has not undergone a sleep study and the oxymetry tests, while indicating dangerously low oxygen levels when sleeping do not meet Medicare's criteria for medical necessity.  The provider of the oxygen condenser had contested this ruling months ago and Medicare's EOB is their final ruling of that appeal.

Here's how the logic essentially goes.

  1. To determine if Lyn needs nighttime breathing support, she must under go a sleep study.  
  2. The doctor who oversees the sleep study requires that the sleep study be conducted in a sleep lab.
  3. Lyn gets extremely anxious outside her home environment at night and has refused to cooperate.
  4. Anxiety meds would calm her.
  5. The sleep study cannot be conducted while she's on the anxiety meds because they need to monitor her breathing when she's unmedicated.
  6. Mom's presence helps calm her.
  7. Mom would not be allowed near enough to touch Lyn during the sleep study because the contact would throw off the readings of the sensors.
  8. The doctor will not authorize a mobile sleep study because the readings are not considered good enough.  Therefore, no sleep study.  Therefore, Medicare refuses to cover the equipment despite all the documentation requested and received in support of the equipment.  
Oxymetry tests indicate a blood oxygen level drop into the 30s during sleep.  As a result of the above, Lyn's primary care physician ordered the oxygen condenser to provide her with the breathing support she needs.  Without the sleep study, she's unable to receive a CPAP device.

So, now Medicare has denied the claim for the condenser and without coverage the unit currently in their home will be removed shortly.  This is where Mom steps in.  She knows that Medicare has denied, been challenged and denied again.  She knows the coverage will continue to be denied unless Lyn submits to a sleep study.  Lyn continues to refuse to cooperate.  So... Mom did a bit of detective work and learned that she can purchase an oxygen condenser as long as she has a doctor's script for the device.  The purchase is out of pocket and will not be submitted to Medicare.

Mom's got an appointment with the doctor tomorrow already scheduled and plans to walk out with the script in hand.  She's made arrangements for the purchase and should have a new device by the end of the day.  The goal is to have it in place before the current device is removed.  Because of her rapid action, Lyn should have the continuous nighttime breathing support that she needs.

That's quality care.

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