Blue Cross denying all sleep disorders

[yoshald]

Here's my first post on the board, so hello. Too bad it's because I'm having trouble with insurance. I changed health insurance plans in August (went back to university). Same company, Blue Cross of Minnesota. I had a single plan for years with no problems. I read the offered plan summary and exclusions, and called to verify BC would cover CPAP supplies, which they said they would at 80% under DME (I'm doing everything in writing or recording from now on). I alerted my supplier of the change, and gave them my plan digits, and they said I was covered at the expected 80%. Blue Cross has denied all claims for hoses, masks, regular supplies thusfar.

You can see the plan here: http://www.shb.umn.edu/downloads/2012-2 ... HBP_TC.pdf and search for "apnea"

It contains: 94. Expenses incurred for services or supplies for the diagnosis and treatment of sleep disorder, including, but
not limited to apnea monitoring and sleep studies. And that's what they are citing when I called them, and also when I emailed the university's director.

I had interpreted this differently before signing up, than they do now. I have a feeling someone there is taking things too literally (or not enough). Does your plan say something worded like that? Also in my plan, you'll see with prior approval, they cover surgery that treats sleep apnea, which isn't as mainstream leading me to think they didn't think this through. And wouldn't they exclude the obvious "but not limited to CPAP machines"? They exclude "appliances" which are the dental mouthpieces and is a pretty standard exclusion. (I actually paid out of pocket for one years ago, and it irritated my jaw so bad, I gave up on it.)

I just can't believe they don't cover sleep apnea cpap treatment, or even sleep studies (I don't need one). Why do their other plans cover it? Treating SOA prevents all kinds of expensive problems, including death! I was prompted for a sleep study a decade ago, when i had something resembling a stroke that put me in the hospital for 3 days of testing. I went numb on one side of my body and I couldn't speak for about an hour, but was fine after that. Neurologists ruled out stroke and TIA and could only hypothesize I had a hemiplegic migraine. Never happened before or since, thank goodness.

I've never appealed before, which seems to be my next step. Any advice on that? Thanks in advance.

[Janknitz]

Sounds like a bait and switch to me but the problem is proof. You should appeal in writing. It helps if you can cite the date, time, and representative who told you SA was covered so they can review the tape ("some calls are monitored for quality assurance purposes") and show the paperwork you were given that never mentioned an exclusion for SA.

File a complaint with the state regulatory agency, and your university, too.

Sorry to say it's a long shot.

[kaiasgram]

Hi yoshaid -- Unfortunately that item 94 under Exclusions is pretty darn clear. Apnea and CPAP treatment and supplies are not covered. My guess is that the rep you spoke to on the phone gave you bum information -- an all too common occurrence with large insurers and their call centers. But I would be surprised if the rep's error constitutes grounds for an appeal, since they would say it was your responsibility to read the terms of coverage before enrolling. I agree with you, it's ridiculous to not cover treatment and supplies for OSA.

If the list of exclusions was sent to you after you spoke with the BC rep on the phone, that might be grounds for an appeal but I still think it would be difficult to win. Any chance of getting help from your university's health center? They should have a specialist there who might have some advice about what to do. Good luck, and sorry about what happened.

[Denial Dave]

I've got BCBS out of minnesota & they are paying 80% for all of my supplies AFTER I reach my annual deduction level.

Could they have rejected your submittals but applied it towards whatever your deductuble is?

[squid13]

There are a lot of different BC/BS insurance plans out there, maybe you should shop around and find a better plan.

[Johnie Boy]

You may want to approach the coverage in a slightly different way. On their web site search for the Medical Policy for the treatment of Obstructive Sleep Apnea. You may find within the policy equipment and supplies listed by procedure code. A CPAP unit will have a procedure code of E0601. Supplies will be listed as “K” codes. I don’t know the codes but items such as headgear, mask, full face mask, nasal pillow, etc., will each have a procedure code. Further, each supply should also have the yearly quantity and frequency allowance.

You may be able to Google for Medical policy for your Insurance provider.

[RandyJ]

Supplies such as masks, mask parts and hoses (billing codes beginning with "A") are not covered under the DME benefit in my Anthem Blue Cross of CT plan either.

[MyIdaho]

I've got BCBS out of minnesota & they are paying 80% for all of my supplies AFTER I reach my annual deduction level.

Could they have rejected your submittals but applied it towards whatever your deductuble is?

I have BC in Idaho through the University of Idaho and Denial Dave's comment is spot on for me. Right now I am paying 100% of my sleep apnea related (and other medical) costs until I have met my deductible. I do get the much lower BC negotiated rates for cpap supplies and equipment from my DME.

[johnthomasmacdonald]

I thought it was only the evil gubmint that denied necessary medical care and got between you and your doctor

[hyperlexis]

The link doesnt work so I cant see the policy. Tried in IE and Chrome and both wont open it. Possibly the site page is down.

However there is a cached page on google for the "2012-2013 Comprehensive Student Health Benefit Plan" at Univ. of Minn. that is adminstered by BCBS and that states that they DO cover DME equipment, however they first require Prior Authorization by the plan for multiple things, including any medically necessary DME (if you go to an 'out of network provider'). One could argue that CPAP equipment is prescribed, and is medically necessary DME.

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
"The Claims Administrator reviews services to verify that they are medically necessary and that the treatmentprovided is the proper level of care. All applicable terms and conditions of your Student Health Benefit Planincluding exclusions, deductibles, copays, and coinsurance provisions continue to apply with an approved priorauthorization, preadmission notification, preadmission certification, and/or emergency admission notification.Prior authorization, preadmission notification, preadmission certification, and/or emergency admissionnotification are required. Prior Authorization Prior authorization is a process that involves a benefits review and determination of medical necessity before aservice is rendered.Minnesota In-Network Providers are required to obtain prior authorization for you. You are required to obtain prior authorization when you use In-Network Providers outside Minnesota and Out-of-Network Providers. However, some of these providers may obtain prior authorization for you. Verify with yourproviders if this is a service they will perform for you. If it is found, at the point the claim is processed, thatservices were not medically necessary, you are liable for all of the charges. The Claims Administratorrequires that you or the provider contact them at least 10 working days prior to the provider scheduling thecare/services to determine if the services are eligible. The Claims Administrator will notify you of their decisionwithin 10 working days, provided that the prior authorization request contains all the information needed to reviewthe service. The prior authorization list* is subject to change due to changes in the Claims Administrator’s medical policy. Themost current list is available on the Claims Administrator’s website or by calling Customer Service.

"• Durable Medical Equipment (DME), prosthetics and supplies including but not limited to:unlisted DME codes over $1,000; functional neuromuscular electrical stimulation; manual and motorizedwheelchairs and scooters; respiratory oscillatory devices; heavy duty and enclosed hospital beds; pressurereducing support surfaces (group 2 and 3); wound healing treatment; continuous glucose monitors; aminoacid-based elemental formula; bone growth stimulators; communication assist devices; and microprocessorcontrolled prosthetics"[....]




So are you on the student health plan, or an employee plan? I can't believe the plans would be much different in what they cover. I would even think that workers would get better coverage than the plans offered to students, if anything.

[johnthomasmacdonald]

oh, i also have horizon blue cross/blue shield here in NJ and so far they've denied every sleep apnea related cost - i've paid for my sleep test at home, all my machines (3) and all my masks and supplies ( around 10 I'd guess)

of course every other charge I've ever had with them has been a huge hassle - my colonoscopy was supposed to cost me $200 up front and THAT IS ALL - i checked this out before surgery with the hospital, blue cross and my doctor. They sent my pathology off to a non-in network lab so i keep getting billed for that ( as if i could control who they sent the path samples off to ) and the hospital (which is in network for my insurance company- the ONLY reason i went to it) keeps sending me a bill for $823 and no matter how often i send them my report from blue cross saying i owe $0.00 they say " no, we've looked into it and decided you owe us $823 "

Trying to get insurance to pay for my and my sister's health related charges ( who has Multiple sclerosis, lymphedema, one leg, and chronic bedsores and is on medicare and has supposedly the best insurance her hospital has ever seen ) is a FULL-TIME JOB - we average about 10 bills a day by mail and 5 calls a day from billers ( including saturdays and sundays)

although i'm sure it's all my fault - as one here told me that it was my fault because i had too cheap a policy - around a thousand a month just for me with no pre-existing illnesses - i've noticed that many here seem to feel it is never the dishonesty of the insurance companies ( funny that those people saying this are usually on medicare)

[chunkyfrog]

I have a couple of friends who now work for Wal Mart.
Their insurance covers PSG's; but NO equipment or supplies.
And one is a department manager, who uses a Bilevel machine.
A very old one, unfortunately. Others remain untreated.
So is this the work of a company "death panel"?
Maybe a few demonstrators standing out in front of the TV cameras.

[johnthomasmacdonald]

chunky frog - it's ONLY a "death panel" if it involves the gubmint. The constant denial of care by insurance companies is just GOOD BUSINESS. In the USA, BY LAW, every corporation MUST do everything it can to maximize profit for the shareholders - any conscience or concern for the community can ONLY be justified if it improves the return to the shareholders. We also have given corporations the rights of a Human being. A human being who thinks this way is a Sociopath - by definition. So why should anyone be surprised that corporations don't care whether people die if it helps the bottom line.

[retrodave15]

I guess they would rather pay for the treatment of the accident victims instead of getting at the root cause of some accidents.
http://well.blogs.nytimes.com/2013/01/0 ... jor-risks/

I scheduled my appointment with my doc after several times of riving to work and not remembering about 20 miles of it. I have a 45 mile trek into work through rural Ohio every morning.

[chunkyfrog]

I honestly don't see the difference.
The bottom line is important everywhere, even in "charities".
OSA-impaired employees can cost a company far more than the prevention.
It's not good business--it's short sighted and stupid.