Insurance denied CPAP coverage -- now what?

jonquil · Post by **jonquil** » Fri Apr 07, 2006 2:54 pm

Even though my ENT thinks the apnea is worth treating because of daytime exhaustion, and even though my blood ox got as low as 75%, Blue Shield of California refuses to cover CPAP for me; I "don't meet the criteria". I'm trying to get further data, and have asked my ENT, a sleep apnea specialist, to launch into the appeal process.

What success have the rest of you had in getting insurance to cover CPAP even if you're underneath the "official" levels? I only had one apneic episode, but several hypnopeic and low blood oxygen.

Guest · Post by **Guest** » Fri Apr 07, 2006 3:14 pm

your ENT or doctor is not doing his/her job and following the correct procedure.

If your doctor suspects you have OSA, they have to document the symptoms of such and submit a letter of medical necessity to your insurance company for further diagnostic tests in this case, an overnight PSG. Once pre-approved by your insurance (ask how much it will cost in deductible), they to send you on to a sleep lab where you have a overnight PSG, that is the only diagnostic test that most insurance will accept.

He/She also has to submit this letter of medical necessity for the sleep study, unless you have had a previous stroke and/or heart attack.

They cannot just send you home with an overnight pulse oximeter for the diagnosis, most insurance won't accept the Pulse Oximeter readings because they are not very accurate. When you go in for an overnight PSG they connect you not only to a pulse oximeter but 12-16 leads, a microphone which monitor for brain wave activity, snore vibrations, leg movements etc. Then together from all these measurements they conclude you have OSA where you then begin some sort of treatment.

jonquil · Post by **jonquil** » Fri Apr 07, 2006 3:16 pm

I should have been clearer. I did a full all-night apnea study at the Blue Shield-approved sleep center, electrodes everywhere. I was then sent for CPAP titration, and again did that all night. Then my ENT wrote a prescription for CPAP; Blue Shield has refused to authorize it.

Guest · Post by **Guest** » Fri Apr 07, 2006 3:18 pm

If your PSG indicated severe oxygen desats, perhaps it's possible you don't need CPAP, but instead need supplemental oxygen at night. I would ask about that in the interim, because you would qualify for supplemental oxygen. Just a thought.

NightHawkeye · Post by **NightHawkeye** » Fri Apr 07, 2006 3:30 pm

jonquil wrote:Then my ENT wrote a prescription for CPAP; Blue Shield has refused to authorize it.

Jonquil, if you think the ENT diagnosis was correct, then why not simply buy an xPAP from one of the online suppliers and submit the bill directly to your insurance. Maybe they'll pay, maybe they won't.

On the other hand you could argue with your insurance from now until the time you die (which, by the way, according to some studies will be sooner than if you're treated).

Regards,
Bill

Wulfman · Post by **Wulfman** » Fri Apr 07, 2006 4:13 pm

jonquil wrote:I should have been clearer. I did a full all-night apnea study at the Blue Shield-approved sleep center, electrodes everywhere. I was then sent for CPAP titration, and again did that all night. Then my ENT wrote a prescription for CPAP; Blue Shield has refused to authorize it.

But.....as "guest" mentioned about the "pre-approval".....did you call your insurance provider BEFORE you had your sleep studies done and get "pre-approval"? Is THAT what they're hung up about or are they saying that they don't/won't cover CPAP therapy?
This area can be a sticking point with the insurance providers.

Good luck.

Den

bulldoger · Post by **bulldoger** » Fri Apr 07, 2006 8:00 pm

You will have to send the appeal. If your sleep study showed that you needed it then they should have to cover it. If your denied on the first appeal then have the raise it to the second level. I just have blue cross finally pay for my sleep study and cpap for 11/04 just have to keep appealing.

jonquil · Post by **jonquil** » Fri Apr 07, 2006 8:13 pm

I got pre-approval from my insurance company for both sleep studies, the original study and the titration. My ENT, who is a Stanford-trained sleep specialist, reviewed the study results and said that I had mild apnea that needed treating because of my daytime symptoms. She wrote a prescription for APAP. The insurance company denied the request. Now I am appealing through the insurance company process.

Guest · Post by **Guest** » Fri Apr 07, 2006 8:22 pm

Jonquil, I also have Blue Cross (Federal employee Program, FEP, which is a pretty crappy contract w/BCBS, but it is covering my treatments so far, and XPAP rental. I knew someone who worked for an insurance co., and they were required to "File 13" x number of claims a day/week, hoping the claimant would give up. I would simply resubmit the claim; if that doesn't work, take the next steps others have suggested. Good Luck! I don't know why there are so many walls put in our way; it's frustrating enough!

wading thru the muck! · Post by **wading thru the muck!** » Fri Apr 07, 2006 8:22 pm

jonquil wrote:I got pre-approval from my insurance company for both sleep studies, the original study and the titration. My ENT, who is a Stanford-trained sleep specialist, reviewed the study results and said that I had mild apnea that needed treating because of my daytime symptoms. She wrote a prescription for APAP. The insurance company denied the request. Now I am appealing through the insurance company process.

jonquil,

My insurance company denied approval every step along the way... but on appeal they agreed to go forward and ultimately covered two sleep studies and my apap. Seemed to me that it was their standard practice to be disagreeable on the first attempt.

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CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, Prescription, APAP

TerryB · Post by **TerryB** » Sat Apr 08, 2006 8:04 am

I'm new at this myself at five weeks on the hose so forgive me if I'm all wet. I think the problem from the sleep study is the report of one Apnea event and the rest Hyponeas. A CPAP can't do anything for Hyponea events, right? Sombody suggested supplimental O2 and I would think that would help raise the saturation levels where air pressure from CPAP would not. In fact CPAP might INCREASE Hyponeas. The affected sleep disorder does not indicate CPAP right?

TerryB

ozij · Post by **ozij** » Sat Apr 08, 2006 9:07 am

A CPAP can't do anything for Hyponea events, right?

Wrong. Wherever did you get that idea?
A CPAP can treat hypopneas very well, and does it for many people, including past and present member - as well as guests - on this forum.

O.

wading thru the muck! · Post by **wading thru the muck!** » Sat Apr 08, 2006 11:02 am

TerryB wrote: In fact CPAP might INCREASE Hyponeas.

TerryB,

Who is telling you this stuff??? Except in rare cases such as people with unusual airway physiology (tumors/polyps etc..), positive airway pressure will counteract narrowing of the airway, AKA "hypopnea"

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CPAPopedia Keywords Contained In This Post (Click For Definition): CPAP

Moogy · Post by **Moogy** » Sat Apr 08, 2006 11:56 am

TerryB wrote: A CPAP can't do anything for Hyponea events, right?

TerryB,

Maybe you are thinking of central apneas, which cannot be fixed by a CPAP. Too high a pressure on a CPAP may be able to actually cause centrals. (I am not sure this is correct, but many believe it to be so. Maybe someone more experienced than I can speak to this.) This fear/belief/fact seems to be the reason that some providers think that patients cannot be trusted not to crank up the pressure too high, so they don't tell us how to reset the machine.

Regards and happy sleeping,

Moogy

Guest · Post by **Guest** » Sat Apr 08, 2006 6:15 pm

Why is it that a doctor can put you on BP medicine for life, do almost any sugery, spend thousands a year on test etc, and the insurance companies have little or no say so. Yet, for OSA treatment which is by comparison cheap and effective, they just stone wall?

Insurance denied CPAP coverage -- now what?

Insurance denied CPAP coverage -- now what?

Why ar we second class patients?