Insurance denied CPAP coverage -- now what?

Guest · Post by **Guest** » Sat Apr 08, 2006 6:19 pm

See I told you I was all wet. Actually sweat from rebuilting the fence. Absolutely I was thinking of centrals. Sorry.

TerryB

wading thru the muck! · Post by **wading thru the muck!** » Sat Apr 08, 2006 7:01 pm

Anonymous wrote:See I told you I was all wet. Actually sweat from rebuilting the fence. Absolutely I was thinking of centrals. Sorry.

TerryB

TerryB,

No need to be sorry! All these terms can be confusing and lord knows we sure don't get any help understanding them from the docs.

So you had mostly Centrals?

chdurie2 · Post by **chdurie2** » Sun Apr 09, 2006 10:11 am

i agree that one apneic episode and several hypoapneas sounds low for cpap insurance coverage, even with daytime sleepiness. it was a few years ago, but as i recall, the insurance company wants to see at least five events--i forget whether they were apneas or hypoapneas. i remember because my doc said i was right on the borderline, and he said he hoped the daytime sleepiness stuff would throw me over the edge. what were your daytime sleepiness test results? the thing where they wake you in 4-5 20 minute intervals? i was virtually unrousable, not a good thing, since the measurement is supposed to be whether you fall asleep after being roused and the ability to be awakened is presumed. didn't your doc warn you that you might not get insurance approval for cpap equipment? certainly, go through the appeals process, and it might be that if you throw enough paper at them, they'll back down. it also might be that they won't because your claim is not strong enough--i know nothing about this oxygyn measurement. do people get cpap for that? i thought it was just apneas and hypoapneas, but i don't know.

Roger... · Post by **Roger...** » Sun Apr 09, 2006 12:35 pm

According to the Sleep Center where I was tested, there is a minimum AHI value that Blue Cross (my insurance) must see to approve any follow-on treatment. My memory might be failing here, but I think the level is around 16. Take a look at your sleep study and see where it came in to see if that is the issue you are dealing with the insurance company. If that is where you problem is, then talk to the sleep center and try to get them to explain why they didn’t explain the insurance requirement before, and how they can justify the process even though you don’t meet the insurance criteria.

Once you have your facts in hand, you’ll be in a better position to argue your appeal because you can base it upon the merits of the issue instead of letting the insurance company stand on some preset number that really isn’t appropriate in all situations. This is where your MD can play a larger role when they write the medical necessity statement. In their statement they can deal with the desaturation issue as being the larger issue, so that whomever needs to approve the claim will have a medical basis for ignoring the preset value.

When trying to work any appeal, always give the approval process some means by which they can justify a change in ruling. If you leave it up to them to find a reason, then you’ll be waiting a long time for someone to care enough to check into why it should be approved given how many claims they process in a day.

chdurie2 · Post by **chdurie2** » Sun Apr 09, 2006 1:12 pm

roger--

great stuff! totally right on. you gotta check everybody. maybe sleep center didn't even bother trying to explain other reasons that insurance company should approve cpap. then the appeal just becomes more rubber stamps of no.

caroline

NightHawkeye · Post by **NightHawkeye** » Sun Apr 09, 2006 3:00 pm

Roger... wrote:According to the Sleep Center where I was tested, there is a minimum AHI value that Blue Cross (my insurance) must see to approve any follow-on treatment. My memory might be failing here, but I think the level is around 16.

Also, a single AHI number can be misleading. If necessary, see if your sleep center can restate AHI so that it is a larger number. (No, I'm not suggesting fraud!) AHI is often stated across the entire night. Medicare requires it across 2 hours I believe, and so your worst 2 hour segment may be considerably higher than the entire night. Also, I've seen that some folks have AHI stated during REM only; again this could be a significantly higher number. Have them restate AHI in whatever way is most advantageous to you. Be as demanding about it as you have to be - the sleep center works for you after all.

Regards,
Bill

Roger... · Post by **Roger...** » Sun Apr 09, 2006 6:20 pm

chdurie2 wrote:you gotta check everybody.

Caroline is right about needing to check everybody. When my sleep center finally got around to faxing the report here, I found all kinds of errors. Unfortunately they needed three tries to get it right, prompting my MD to ask after receiving three different copies, "What happened during the sleep study?” When the errors were pointed out by the changes in the report’s evolution, he paused with the look that projected he was wondering how many other errors were reported for other patients.

Getting a report from the sleep center was a challenge that took many phone calls over three weeks. Through that reminding cycle I discovered the doctor who wrote the report's details lived more than 360 miles south of here and did the report analysis nights in his spare time. I also discovered a lot of unsettling issues at the sleep center that left me feeling lucky I only had to see them one-time.

If you don't have the actual report in your hands, and you don't have a copy of your doctor’s prescription, it will be an up hill battle because both documents must reflect what you want them to approve.

chdurie2 · Post by **chdurie2** » Sun Apr 09, 2006 9:34 pm

roger--

do you have copies of all three reports? that might come in handy in your cause. somebody is going to have to plead your case. don't care if the doc lives 360 miles away and does reports in his spare time--he's still paid to do them competently. would he accept spare change as his compensation?

those reasons are not the only ones for sleep center ineptness. i don't need to go into it but i've had horror stories with centers and docs who had big names. had to go to a not-so-biggie to get competency.

so this doc who was left wondering what else went wrong, can he marshall a good case for you? otherwise, you may have to get all three reports, show them to the insurance company and have another study. yyyycccchhh! you might point out to the insurance company that it would be cheaper to just get you a machine. but not sure they'll go for that.

good luck.

caroline

Guest · Post by **Guest** » Mon Apr 10, 2006 12:25 pm

There is a guy where I work that had this problem. He finally told his insurance company that "if he fell asleep while driving, and an accident occurred, they would be held responsible." It must have worked, because he got his CPAP.

Roger... · Post by **Roger...** » Mon Apr 10, 2006 12:34 pm

Hello Caroline,
My postings were in support for jonquil. They started the thread and I was just trying to give them an example of how difficult it can sometimes be to get a sleep center to do the work correctly. My effort with the insurance is unresolved, but the reasons fall into the range of the right hand loosing track of what the left hand is doing and saying.

Dealing with an insurance company is like shoveling sand against the tide. It gives you something to do while you wait for the tide to go out.

grumpy · Post by **grumpy** » Fri Apr 14, 2006 8:45 am

I fail to see in all this how the dr could send you and the insurance would pay for a titration study if you didn't need some form of Cpap? If you didn't qualify, shouldn't they have refused to pay for the titration study?

Roger... · Post by **Roger...** » Fri Apr 14, 2006 9:01 am

Grumpy,
You are assuming that insurance people think in logical terms. That hasn't been my experience. In my case, I'm still struggling to get my MD to provide a diagnostic code that the insurance company says will be appropriate for DME equipment.

Of course, this code problem doesn't surface before the purchase, during the sleep study or even during one of three conversation I had with them before buying the equipment.

For the sleep study, I had the issue of which testing code was used. That got settled a few months back, but now the insurance company has dug in their feet about the diagnostic code. For insurance people, it is all about playing their game their way when they saw or they use it to say, no pay. In addition, if you don't give them the right answer within a set period of time, the claim is automatically rejected.

It is utterly amazing to me that we pay for this kind of service.

greyhound · Post by **greyhound** » Fri Apr 14, 2006 9:11 am

My insurance company (Aetna HMO) paid for the two sleep studies, but not for CPAP equipment because the policy didn't cover durable medical equipment. Makes a lot of sense, doesn't it?

chdurie2 · Post by **chdurie2** » Sat Apr 15, 2006 6:14 pm

You should ask AETNA what kind of cpap therapy the policy would cover (of course, none) and inform them in writing that you will hold them liable for any accident stemming from your cpap fatigue, as diagnosed by their covered tests, and their refusal to cover the only effective treatment known to treat the medical problem. You may see a shift in their stance.

caroline

p.s. did AETNA put their refusal in writing, or was this something a customer rep told you on the phone?

Bonnie · Post by **Bonnie** » Sun Apr 16, 2006 12:32 pm

Dealing with insurance companies can be almost as frustrating as DME...well OK not quite. I had a sleep study at the hospital, insurance paid for it. I was given a cpap rental, insurance paid for it. I had a home titration , insurance paid for the rental of an auto with a smart card so my doc could find the correct pressure. Insurance paid for the purchase of my Remstar with cflex and equipment, filters, Swift, hoses, etc. What they WON'T pay for is the interpretation reading my doc did to determine my pressure. He charged $700 to do this and the insurance company said home titration is a non proven service. We are currently in appeal with my doc sending a letter , medical articles and proven studies to a bozo doctor who know nothing about sleep apnea yet is qualified to deny charges. Go figure.

With my doctor charging $700 for reading my printouts I figure I am saving the insurance company $36,400 if I read mine myself weekly or $255,000 if I read them daily using EncorePro. Ya think they'd be happy!

Insurance denied CPAP coverage -- now what?

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