WHY... DME air matress not approved for stage 4 coccyx wound?.

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I have a patient with a stage four coccxy wound, regularly see's wound care specialist once a week (also has ulcers on foot), primary doctor wrote a script for air loss mattress but home health agency is saying it is being denied....why?! Please help my patient. The reason told why matress is being denied is because the wound has to be covering 25% of pt trunk. (Wound is 1cm wide). Thanks for any advice or explanation..

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Specializes in Psych, Addictions, SOL (Student of Life).
I have a patient with a stage four coccxy wound, regularly see's wound care specialist once a week (also has ulcers on foot), primary doctor wrote a script for air loss mattress but home health agency is saying it is being denied....why?! Please help my patient. The reason told why matress is being denied is because the wound has to be covering 25% of pt trunk. (Wound is 1cm wide). Thanks for any advice or explanation..

I don't know where the home health agency got their information but it's simply not true. You can look up what Medicare Covers and see that there are very specific criteria for Low Air loss mattress. The stage of the wound is important but there is no criteria as to the size (circumference). The patient's primary care physician has to do a certificate of medical necessity based on the criteria for approval. The home health agency does not do this. I have found many not so legit Home health agencies as well as physician's and dentists who will tell a patient or family that something isn't covered so that they don't have to do the necessary paperwork.

Hppy

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Specializes in Telemetry.

If the wound care specialist is a hcp (MD, DO, PA, or NP) could they write the script/fill out the paperwork as they are probably used to the red tape and know how to state things to make medicare/insurance company happy?

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Thank you for the feed back. The patient has medicare D coverage and medi-cal. Hppy...do you know if medi-cal will approve the air matress. The primary doctor has been great and very concerned as to why her pt doesn't have a matress yet. The primary doctor already wrote a script to the home health agency over a month ago and just the other day said to let her know what more she needs to do. I felt like an idiot in telling her what I was told by the company I work for. I may be wrong but I looked up medi-cal coverage for air matress and if I understood correctly, it said all that is needed is a doctors script?!

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Leigh, this sounds odd but I did call the wound care specialist, they have no problem in writing what ever is needed but I was told by my company that they needed the primary doctors script. Does any of this make sense or is it home health laziness?

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I worked in insurance for a long time. What's needed is a script and medical records describing the wound and what all has been tried. Sounds like laziness to me. Home health agencies are often the worst.

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Specializes in Psych, Addictions, SOL (Student of Life).
I worked in insurance for a long time. What's needed is a script and medical records describing the wound and what all has been tried. Sounds like laziness to me. Home health agencies are often the worst.

A script and a certificate of medical necessity and possibly copies of the treatment record is required. I used to fill out the certificates for a physician who then signed them. It's a two page double sided form. It states what's needed for what condition, how long the equipment is likely to be needed etc.... Once the necessary paperwork is completed it can be submitted directly to the company providing the mattress - if all I's are dotted and all T's are crossed correctly the request should go through without too much difficulty. On a side note (and I don't work for them) Allegro Medical which is where I used to get most of my non custom DME items sell LALM's from 500.00 to 4,000.00 dollars with free shipping. Sometimes it's less trouble to just buy the thing outright.

Hppy

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Thank you so much all for taking the time to share info. UPDATE: you guys are right.....I was really frustrated so I asked the patient to call their insurance to find out the facts about getting the air matress. So they did and the medicare said the bed is 100% covered because she already has a hospital bed. So the next day taa-daa...air matress. Patient and family very happy! Thanks again hppy, Leigh, Carrie!!! Your support definetely helped me find a solution!

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Ps apparently everything was in order from home health agency (that is what i was told) the hold up was with the DME company...

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Specializes in Telemetry.

Great! Hope it's beneficial for your pt.

BTW, does pt use wheelchair? I ask because if they do, they might benefit from a tilt in space wheelchair. My mom has wounds and is unable to walk, and her wound physician got her an awesome chair so when the seat leans back the pressure is on her back instead od coccyx area.

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Welcome to 21st century, Affordable Health Care Act insurance!!! Deny everything that a patient needs to save money, but grab every dollar in premiums they can. There is no understanding of it, and worrying about it is only going to make you crazy.

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.
Welcome to 21st century, Affordable Health Care Act insurance!!! Deny everything that a patient needs to save money, but grab every dollar in premiums they can. There is no understanding of it, and worrying about it is only going to make you crazy.

Um, no, the air mattress is covered. The provider either did not understand or did not want to do the paper work.

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