insurance denied

[ichitumi]

I just got a letter from my insurance that my insurance company has denied further supplies for my cpap saying that my condition is too mild.

According to their new rules, AHI and RDI needs to meet or exceed 15 events/hour in order to qualify. My AHI's only 3.3 and RDI 9.6.

Why do I have insurance again?

[Emilia]

Is your AHI 3.3 WITH cpap or without? the 15 events per hour would be the minimum withOUT cpap...in other words what your sleep study showed. FWIW, 15 events per hour is actually considered MODERATE not mild OSA. If your AHI of 3.3 is what you have averaged while on cpap, how can they deny you coverage for your cpap supplies for therapy that is working for you?

We need some more definitive details from you to understand this...... What insurance company has these 'new' rules? I'd hate to think this is a precedent setting thing that others will follow.

[ichitumi]

I believe it was without. Yes, it was considered moderate at the time. I was just sleeping anytime and everywhere. Feeling much better with cpap. Just a little frustrated with the denial. At least I've still got a small stockpile of supplies for the time being and I bought my own machine instead of going through insurance and renting so I'm good with that for now.

My sleep study said that I MAY have narcolapsy, but I'm afraid to find out.

Thanks for letting me vent.

[archangle]

Be sure to get a paper copy of your prescription and send it to CPAP.com and/or other internet suppliers so you can order your supplies online.

[idamtnboy]

I believe it was without. Yes, it was considered moderate at the time. I was just sleeping anytime and everywhere. Feeling much better with cpap. Just a little frustrated with the denial. At least I've still got a small stockpile of supplies for the time being and I bought my own machine instead of going through insurance and renting so I'm good with that for now.

My sleep study said that I MAY have narcolapsy, but I'm afraid to find out.

Sounds like they've adopted the Medicare criteria. You may need to work on adequate documentation if the the second criteria fits.

CPAP will be covered under Medicare in adult patients with OSA if either of the following criteria is met:
(1) AHI > 15, or
(2) AHI > 5 and > 14 with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke.

[ichitumi]

Thanks. They must have changed their qualification somewhat recently. I do have excessive daytime sleepiness ... even now, just much better with cpap than without.

Winnie

I believe it was without. Yes, it was considered moderate at the time. I was just sleeping anytime and everywhere. Feeling much better with cpap. Just a little frustrated with the denial. At least I've still got a small stockpile of supplies for the time being and I bought my own machine instead of going through insurance and renting so I'm good with that for now.

My sleep study said that I MAY have narcolapsy, but I'm afraid to find out.

Sounds like they've adopted the Medicare criteria. You may need to work on adequate documentation if the the second criteria fits.

CPAP will be covered under Medicare in adult patients with OSA if either of the following criteria is met:
(1) AHI > 15, or
(2) AHI > 5 and > 14 with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke.