Anyone Familiar With Insurance/Billing Policies?

Hello all I was looking for some help with anyone informed on standard insurance/billing procedures. In reference to my last post, I can't tolerate the CPAP (although I haven't tried it much, it causes me emotional stress as well at the age of 22). When I was first diagnosed, I called my insurance company and they said that they only cover the CPAP and that they do not cover oral appliances for sleep apnea at all. Fast forward to now, I go to the orthodontist and they say they are contracted with my insurance company and that it should be covered. I called my insurance company again, and the new person on the phone said that it was covered under durable medical equipment. I am extremely upset at how ill-informed they are. Anyway, here is my question. My insurance company has already paid off the CPAP, and I was trying to suck it up using it over time knowing that was my only option. The oral appliance requires prior authorization. Is there a possibility that they will deny paying for the oral appliance since they already paid for the CPAP? And if that is the case, can I dispute it? I obviously have no evidence of the phone call, so if that is the case I am probably out of luck. The appliance out of pocket is $3000 and I cannot afford to go that route. All the dentists in the area only offer the somnodent, so that is my cheapest option. Any advice/tips are appreciated.

Calling on the phone (unless perhaps you are recording the call) is basically worse than useless for two reasons - you have no way to know if you are receiving accurate information, and no way to prove it if you were somehow mislead, either intentionally or unintentionally. I am dealing with an insurance related issue right now and have received different answers to the same question, or conflicting answers, sometimes on the same call with same person.

You cannot rely on whomever the insurer or other provider chooses to put on the phone to speak to clients. You must have your complete plan documents in your possession, and read and understand them for yourself in order to be sure you know the deal, and sometime to be sure you're not out of your mind

Yeah, lesson learned 100%. It irritates me even more because the oral appliance was my first choice in the first place, and my sleep doctor reccomended it given my age and lifestyle. The funny thing is I remember the exact conversation, and the lady said they didn't cover it before I even finished asking the question. The lady today was kind enough to look into it for me, and said that it would be covered as long as it was for a medical need. Anyway what's done is done, and I cannot go back and reverse the mistake.

I am just wondering if the insurance already having paid for a CPAP will hinder them authorizing my ability to get the oral appliance. I am praying that it doesn't as I want to get this over with and move on with my life. Being unable to get deep sleep is impacting my life on all levels. But I simply cannot afford the $3000 out of pocket is it isn't covered.

You need to get your sweaty hands on the official documents that specify what is or is not covered.
I wish there was an easier way, but that is rarely an option.

I actually did do this as well. Went through the handbook that we have as well as the online version. Neither had anything specific about oral appliances, just durable medical equipment. They will submit the authorization on Monday, so I am praying that it gets through.

It is very difficult to get the "full policy" document, and even if you do, you may not interpret it correctly. They can be very complex. Normally, the best you can do is get everything in writing.

You state what your account is, state the facts of what the question/treatment/equipment whatever is, the circumstances and ask for an official response. This is typically now days done via their Secure mail system via their website. If the answer is incomplete, ask again asking for clarification.

Later if there is a dispute, you have written documentation of the responses you got.

When dealing with a DME (visit), record it. Use your phone or recording device and keep the recording. Also, keep and review all documents. Don't allow documents you sign to have blank spots to be filled out later. Write "was blank" in those areas before signing.


BTW if I had been tested when I was 22, I bet I would have started CPAP then. I clearly had sleep issues, already snored loudly when I was "sleeping" and was fairly fit and trim at that time.

When I was 22, cpap had not been invented yet.
I probably would have had no treatment, as a tracheotomy was for severe cases.
If only . . . Ah, well, water under the bridge.

The actual contract you have with your insurer is called the "Evidence of Coverage". You must request a copy in writing and state law dictates how long they have to provide you with a copy after a written request. That will tell you what's covered and how. If they say the oral appliance isn't covered because you already have a CPAP, demand they tell you what page that's on in your EOC. It's probably NOT there, that's how you appeal the denial.

If you will take my advice try to argue for a machine you can tolerate. I had 2 different oral appliances. They were. Waste of time. Once you find the correct mask for you and it may take some time you have to work at accepting it ad part of your sleep hygiene.
I cant imagine anyone cohld be more claustrophobic than I was . As far ad the insurance Dts can sometimes help with rhat part showing need and coding correctly. Its a journey! Best of luck

Please excuse my spee checker

spell