Will My Insurance Pay for My CPM Machine

Isn't it frustrating that we pay thousands of dollars per year for the “privilege” of having health insurance, only to find out they are not going to cover a procedure or piece of equipment we need?

Sound familiar?

I wish it wasn’t, but unfortunately, I hear this all too often. I get calls on a daily basis asking whether insurance will pay for certain kinds of medical equipment, such as Continuous Passive Motion (CPM) machines, Sequential Compression Devices (SCDs), or cold therapy machines.

Unfortunately, the answer is not cut and dried. It varies based on a number of factors, including the type of surgery, type of machine desired, type of insurance, benefits allowed by your insurance, and other treatments tried or available to your doctor

I wish it was a simple yes or no (mainly yes), but it usually involves far more work.

We Can Help Navigate Your Insurance

We, here at The Medcom Group, have patient care representatives who help patients determine whether they have coverage for certain items, either rental or purchase, by speaking with their insurance company on their behalf.

If necessary, we can submit for preauthorization and work with your doctor's office to obtain the documentation and medical notes your insurance company requires. We can also investigate and appeal a denial when appropriate.

However, obtaining authorization does NOT guarantee that the insurance company will actually pay for the machine. Unfortunately, this is precisely where problems can pop up.

What If Insurance Doesn't Pay?

We do offer another great option for you: prepay pricing, which can be significantly less than the insurance billing price. Here’s how it works.

If we bill an insurance company, we have to have staff to obtain the preauthorization, handle the paperwork, submit the claim, follow up with the insurance company, and make sure the bill is actually paid. It is a lot of work and takes a lot of people to accomplish.

Our website prices are our prepay prices. If we bill insurance, the amount we bill can be significantly higher because of the additional work involved. If the insurance company ultimately denies or only partially pays the claim, including deductibles, copays, or other balances, you are responsible for the remaining amount.

You can also use our prepay pricing and submit the claim to your insurance company yourself. We can provide the documentation you need to file the claim. This option lets you know your rental expense upfront instead of waiting to see what your insurance company decides to pay.

Don't Believe Every Insurance Coverage Claim

Now, I like to think that I am knowledgeable about my field and profession. Part of this is knowing what our competitors are doing or advertising.

I have seen claims on other companies’ websites that imply ALL CPMs are covered by insurance, regardless of the circumstances.

I hate to be the bearer of bad news, but that is not the case.

For instance, let’s look at Medicare coverage for CPMs. Medicare covers a CPM for patients who have received a total knee replacement when specific requirements are met. According to current CMS guidance, use of the device must begin within two days following surgery, and Medicare limits coverage to the portion of the three-week period following surgery during which the device gets used in the patient’s home. CMS makes payment for each day the device gets used at home, up to that 21-day limit.

While details are subject to change, we’ve found that Medicare CPM coverage applies to a first total knee replacement on that knee, rather than a revision or manipulation under anesthesia (MUA).

What this means for you is that Medicare does not provide blanket CPM coverage simply because your doctor prescribed one. The national Medicare policy specifically covers CPM following total knee replacement; it does not establish the same coverage for shoulder, elbow, ankle, or other surgeries.

Private insurance plans can have different rules, which is why you need to check your specific benefits rather than assume that Medicare’s rules apply to your plan.

We Want to Be an Asset to Your Recovery

A lot of insurance companies will pay for CPMs, SCDs, cold therapy machines, and other available equipment. But coverage depends on your specific insurance, your procedure, your benefits, and the requirements of your plan.

We want to be an asset to your recovery, but not at the expense of our integrity. We will not rope you into accepting equipment if we know your insurance company is unlikely to pay.

Here at The Medcom Group, we prefer to be honest and upfront with you. Dealing with insurance companies can be a hassle. Let us use our decades of experience with our products and with insurance companies to help you understand your options and decide what works best for you.

The Medcom Group has been helping patients recover at home since 1988. If you have questions about your medical equipment needs, call one of our Patient Care Representatives at (877) 668-0961 or contact us through our website.