How do we get Medicare to continue paying for his transportation?

Marc j. asked...

Hi. My father is 83 years old ( also a veteran of WW II ). He has been receiving dialysis treatments at a local center for about 3 years now. He recently had some complications which effected his ability to walk. He can walk although only with a walker now. He was prescribed oxygen which he uses at home a few hours a day which helps him. Medicare currently is paying for ambulance transportation to and from the dialysis center. They have indicated that they MAY curtail paying for such transportation since they question whether the oxygen is a medical necessity. Is there any suggestions as to how to (a) compel Medicare to continue to cover the transportation, (b) how to challenge Medicare if they terminate such coverage, and (c) any other resources where my dad could obtain coverage for such transportation?

Expert Answer

Medicare Part B can pay for ambulance transportation to and from a patient's home only in very limited circumstances. Normally, Medicare Part B does not cover routine transportation for a patient to or from home in nonemergency situations. However, Medicare Part B sometimes covers nonemergency ambulance transportation between home and a place of treatment, such as your father's dialysis, if the patient's doctor certifies in writing that transportation in something other than an ambulance would endanger the patient's health. Even a doctor's prescription, however, doesn't guaranty Medicare Part B coverage of nonemergency ambulance coverage. That's because Medicare will make its own judgment about whether the transportation is "medically necessary."

In your father's case, Medicare will look at two different things. It will decide whether your father's oxygen treatment is medically necessary. If it determines that the oxygen is medically necessary, it still has to decide whether the ambulance is also medically necessary. Even if it determines that the oxygen is no longer medically necessary, it could still decide to cover the ambulance transport if your father's doctor convinces Medicare that the ambulance transport is medically necessary. As to both matters -- the oxygen and the transport -- your father's treating doctor is the key. Let him or her know about the situation and ask if the doctor will provide an update to Medicare describing why the oxygen and transportation continue to be medically necessary for your father.

If Medicare decides no longer to cover the oxygen and/or the transportation, your father may immediately appeal the decision. The procedure is fairly simple, explained on the back of the written Medicare Summary Notice that your father will be sent which will state whether Medicare is approving or denying coverage. As with Medicare's initial coverage decision, much will depend on how well your father's doctor explains the medical need for both the oxygen and the transpportation.

For more detailed information about the appeal process, you and your father can look at Section 3 of the official Medicare online pamphlet Your Medicare Rights and Protections. Also, your father can get free, expert assistance with his appeal from a local office of the State Health Insurance assistance Program (SHIP) or Health Insurance Counseling and Advocacy Program (HICAP); to find the local office nearest her, you can contact your state SHIP or HICAP office.