Insurance rejects Dr's Sleep Study referral

What a shitty day this has started to be. Got a call from the sleep center, have had this nov 14 apt for over a month now. I'm thinkin oh cool mayb a sooner date, na not this guys luck.... Seems my insurance has rejected it and my appt has been canceled. She did say they were sending paperwork for my dr to possably appeal that decision. Fml no clue what to do now totally wrong, I so need this! Wow

I would call your insurance company and find out on what basis it was rejected. If all else fails -- my neighbor had a similar problem -- his doctor sent a letter to the ins. co. and had a sleep study about a month later.

You should find out what the basis for the denial was. Then you may have to carry through the appeal--the sleep clinic and doctor may help you, but they rarely follow through without you "driving the boat".

When you call your insurer, ask them to send you a written denial, and also ask how to request the "Evidence of Coverage" (EOC). The EOC is the actual contract between you and your insurer, but you NEVER see this unless you ask. Generally you must request this in WRITING, and state law usually dictates how long they have to provide it to you on written request. In California, for example, it's 10 days.

If the reason they cite for denying pre-authorization of your sleep study is not in the book, then you have to point it out to them in writing. Here's an example:

My daughter needed leg braces. She needed two different kinds--fixed braces to position her legs during the night and articulated braces to permit walking during the day. She got her day braces, but when it came time to order night braces the insurance company denied the claim because she couldn't have "two sets of braces." There was no such restriction in the EOC. I had to go through two levels of appeal, but they couldn't make up a rule that was not already in the EOC. They paid for both sets of braces. Note that this appeals process took a couple of months, and neither the doctor nor the orthotics maker were very helpful, I had to do it all on my own. But worth it, since a set of braces cost a small fortune.

Be persistent. Keep copies of everything and a log of who you talk to when about what for phone calls. Never rely on what anyone tells you verbally, always follow up with a confirming memo in writing. Send requests by certified mail so you have proof they received them and when if the appeals steps are time-sensitive.

You may not be able to keep your November 13 date, but if you are persistent you may be able to get your sleep study. Note the insurance company may be doing this simply because you probably have a new deductible January first so it will cost them less if they delay you.

The "insurance" is state Medicaid if I remember correctly and Medicaid is an entirely different animal.
Most likely the medical need wasn't clearly stated since this is sort of a special situation.
OP has an appointment with sleep doc then end of Dec but his primary care doc was willing to go ahead and get the sleep study ahead of time because it is going to be needed.
We were attempting to save some time.

I don't know what wording might be needed from the primary care doc to get the criteria met for another sleep study. It's Medicaid and criteria can vary widely from state to state.

Can't see the sleep doc earlier because she is out on maternity leave now.
Don't know if there is another sleep doctor in the practice who could maybe be seen sooner or at least get the correct wording needed to meet criteria for another sleep study.

Maybe the insurance people were Mets fans too!

Sheriff

or were not

Letter arrived today from insurance, guess everyone got one - me, sleep center, doc



Called Doc after receiving the call from the sleep study place - the office girl who is new lol was telling me that the doctor does not deal with this type of issue, even though the sleep center told me they were sending the Dr the info for him to appeal..... I asked to talk with someone diff - I spoke with one of the reg nurses, she said she would personally see that it was handled correctly and that my doc filled out and sent back to the insurance the proper stuff.....

shrug, knew I would come across some flack or push back from insurance but did not think that would happen till they saw the script for the new machine not prior to the dang test, they had no issue 3-4 years ago approving one....

I dunno, dang knew it was going too smooth had my appt for sleep study - a month later new sleep dr appt

It seems like there's a big push to require in-home tests now, followed by titration on an APAP at home, and only allow the in-lab study if the in-home test doesn't suffice for some articulable reason, or can't be done for some reason, or (like me) you just can't sleep with that halo thing on your head. That's the situation the denial letter seems to be describing, although your doctor probably has to medically justify ordering an in-home study anyway. It's often easier to sleep at home, but of course you get MUCH less info out of it, and often enough end up in the lab anyway. But if in-home is not going to work for you for one of the reasons they state, probably the doctor should take care to argue that point.

Mets...

yea i blame Pugsy's voodoo doll on the Mets situation

and well this Dr is the best i have ever had my entire life, love the guy. I am sure he will get it done or ill have to wait another month to see the Sleep Dr and have her re-referral what i was trying to avoid and speed things up a little and have it all ready for when i see her Dec 22nd...... that and the fact i or we were hoping for a split sleep study with ASV if centrals are present (i have over 100-200 a night) so yea not all too sure the home thing would even be worth it - I prob have more data in sleepyhead then I would get with a home study? well i shouldnt say that as I have no idea what the in home ones like

Hey everyone..anyone...not familiar with OP's history....

Short version...he had a home study approx 3 years ago...diagnosed with OSA and given APAP machine.
Sort of didn't do anything until this summer and decided to try cpap/apap again.
In the meantime between first sleep study and now has had to take some pain meds that seem to be seriously causing centrals.
There's another thread where we tried all sorts of things to reduce the centrals and were unsuccessful.
This up coming sleep study was supposed to be a split study anticipating the centrals and using ASV for the central apnea and the obstructive apnea...sort of have it done before upcoming sleep specialist visit in late Dec because it is going to have to be done anyway.

So we have tons of cpap/apap data from both PR S1 and S9 machines documenting a boatload of centrals that we can't reduce and he needs special follow up with a sleep doctor and most likely ASV machine like the S9 Adapt, AirCurve 10 ASV or the PR S1 960 (or whatever it is called in the newest Respironics model).

This is a special and complicated situation. He needs something to deal with the centrals and the obstructive apneas.

I would agree with Darth Lady. Seems to me that they are refusing a lab study, but that home study looks to still be an option.

I don't think a home sleep study is a particularly useful option at this point.
Unless a Type II is done and using equipment that is really accurate in terms of central identification.
Most of the time these Medicaid approved home studies are finger tip pulse ox and flow studies without necessary equipment to properly identify centrals because those studies are less costly.

Between "Medical problems likely to interfere with a home study" and "certain already diagnosed sleep disorders," along with the rest of the history here, there are ample medical necessity grounds for even the most pigheaded insurance company.

The problem is, you have to say the magic words. And sadly, without access to the specialist, it's hard to come up with the magic words, and the people (robots? computers?) doing the reviewing can just smell that the applying doctor "doesn't speak the language." It's sad.

Is it possible that, even on maternity leave, the sleep doctor could/would be willing to contact the insurer?

Short version..."he had a home study approx 3 years ago...diagnosed with OSA and given APAP machine." - it was a in lab study but yea thats minor point in the whole thing.

Thanks so much for all your replys and time spent with me, it means a ton!!

Yea its pretty frustrating but I will get thru this, they cover 100 Percent evertything so far my dr appts, equip, surgerys whatever but yes i belive they saw my fam dr as a noob in the Terms or whatnot and well its not right but it is wht it is and dumb s I have to put up with to get to the end goal I guess....

I do well havent dropped my orig sleep dr but havent been to an apt to him in over 3 years so like unsure how they are going to act if i call and lay this all on them lol was just hopeing that the flow were had going on with my General Dr stepping up as well he knows I needed it done, that it was going to be 2+ months to see the new sleep dr (all what pugsy said)....l