A recent story on NPR News reported that half of all patients win their appeal of denials by health insurance companies. They told the story of a patient with sleepiness and loud snoring who saw a doctor that recommended a sleep study. The insurance company denied authorization for the sleep study. The patient filed an appeal that overturned the decision, and now the patient is treated for sleep apnea and feeling much better. The story reported findings from a 2011 report from the General Accounting Office showing successful appeals in 40-60% of cases, while another study from California had similar findings of about 50% success.
If your insurance denies coverage for sleep apnea surgery, do not give up
As someone who treats patients with sleep disorders all the time, I have the chance to speak with medical directors from many insurance companies often. These medical directors are generally very reasonable, with favorable reviews of the cases most of the time. Usually, the denials are related to our care not entirely fitting the guidelines that often are either outdated or written to cover only a limited range of procedures. The appeal process often involves the chance to explain the uniqueness of a case and rationale for pursuing a certain course of action, and it is helpful to speak directly with someone who can make allowances outside the set guidelines.
Although some health insurance companies are denying tests and treatment for sleep apnea, presumably because they think sleep apnea is not important, some life insurance companies are rejecting many applications from individuals with a diagnosis of sleep apnea at any point in time. I have written many letters on behalf of my patients, whether to indicate that they have been treated for their sleep apnea (treatment has been shown to eliminate the risks of serious events like heart attack or death) or that someone with mild sleep apnea does not actually have an increased risk of these events, even if moderate to severe sleep apnea does carry the risks. Although these also are not always successful, I am told that they do help.
Let’s just say that the insurance industry has not entirely caught up with science when it comes to sleep apnea. The good news is that reaching out to someone to explain the situation often will result in the correct decision. Filing that appeal is not a waste of time.
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rebecca hammack says:
I work for a medical health system and I do collections for billing. 99% of all sleep studies are denied unless they show medical necessity, ie; heart attack or stroke.
How do you handle this problem? Most sleep studies are done due to Sleep Apnea.
Dr. Kezirian says:
Most sleep studies are approved, in my experience, although there has been a shift towards approving home sleep studies rather than in-laboratory studies.
Felix says:
I was just recently diagnosed with a severe sleep apnea. I did the home study which was approved by my insurance. After my follow up visit with the physician, my condition needs to be treated and would require a cpap machine with mask. In order for the mask fit to my face, I would have to to do a cpap titration study in the lab. I asked the hospital to request for approval from insurance in my behalf. I received a call from insurance as well as the hospital that it was denied. What should I do? Please advise. Thank you.
Dr. Kezirian says:
Another option would be automatically-adjusting positive airway pressure therapy that does not require an in-laboratory study. The right mask can be determined with something called a mask fitting where they check a number of masks to find one that might work well.
Tara Maskill says:
My husband was just denied by his insurance a sleep study to determine if he has sleep apnea…which given his long list of issues for a long period we are sure this is the issue. The insurance company informed me that sleep disorder treatments are not covered under the group plans …how can we get this reversed so that they will cover this?
Dr. Kezirian says:
Whoever ordered the sleep study should communicate with the insurance company, potentially doing what is called a Peer to Peer discussion.
Claire Trouard says:
We have done the Peer to Peer and have been denied for the Sleep Study here in West Palm Beach. My husband and been through all the test and has severe Sleep Apnea. It has been diagnosed by 2 doctors, we are on year 3! The Mayo clinic advised a Sleep Study, denied. His new Pulmonary Dr. advised this last month, denied. He did the Peer to Peer. Now on an appeal process, this is insane! He can’t use the CPAP due to proven breathing issues by multiple specialists at the Mayo Clinic, etc. Yet, the I insurance company still feels the need to deny. Does anyone get approved for the study anymore?
Dr. Kezirian says:
People absolutely do get approved for sleep studies. Often home sleep studies are easier to get approved, but there are good reasons to do an in-laboratory sleep study (polysomnogram) too. Usually the Peer to Peer discussion clears up the reasons for an insurance company denial and allows patient care to move forward. Do not give up!
Lisa Micale says:
I am 53 years old. I was diagnosed with sleep apnea about four years ago…but am sure I’ve had it my entire life…just didn’t know why I was always sooo tired and nauseous every time I woke up from a nap or after sleeping all night. I had tmj surgery 30 years ago and went to the same oral surgeon in recent years do to severe deteroration and pain in my jaw joint. Upon xrays, he discovered also that I have less than a straw to breathe from in both upper and lower airways. I use my cpap faithfully, but continue to snore…I have jaw and pain… and now have estacian ear tube problems caused by cpap pressure….not to mention…I am still always soooo tired that I can hardly function at work and at home. I don’t have cancer, thyroid/hormone problems, nor anemia. It is due to the sleep apnea. I have a very recessed jaw, and at rest, my mouth hangs wide open. Bimaxillary surgery, jaw joint replacement surgery, and upper airway surgery can eliminate my sleep apnea and give me a quality life. My insurance company Highmark Blue Cross Blue Shield of South Carolina does not list sleep apnea nor tmj surgery in their benifits. In fact, it states that it covers nothing dealing with the jaw for sleep apnea nor tmj. My question is…can a noncovered benefit be appealed if found medically necessary? If not, are there any other programs that would pay to have this surgery? I know what all this surgery entails and am willing to go through whatever it takes…..
Dr. Kezirian says:
You can definitely appeal the denial for this surgery because of medical necessity.
Michael says:
I’m a 39 y/o firefighter being treated for work related hypertension. I’m on 8 blood pressure medications a day. In an effort to consider secondary cause of htn the workers comp ins approved a sleep study which determined I have sever sleep apnea. They told me to follow up with my PCP. I did and was denied a titration study by my health insurance. Is it likely I would win an appeal if my insurance new of my the htn medications? Is there any other recommendations I should consider to try to win the appeal? thanks!
Dr. Kezirian says:
You may not need a titration sleep study, as the insurance company may want you to try automatically-adjusting CPAP first. You should ask your doctor if this is an option. If not, go ahead and appeal with your insurance company.
Jordan Goodwin says:
I’m a 25 year old female. I was approved for an at home sleep test which came back as Central Sleep Apnea with no obstructive. Low oxygen and high blood pressure. They recommended that I do 2 follow up tests or at least 2 in one night and that a CPAP or APAP are not going to be as effective as some other type of mask. My Endocrinologist suspects I may have a brain tumor. Insurance denied my sleep studies. I am on the verge of losing my job. This is ruining my life, and hearing that I was denied is making me feel extremely hopeless in every way.
Dr. Kezirian says:
I am sorry to hear it, but you should appeal the insurance company decision if your doctor thinks this is wrong (and ask your doctor to write a letter to accompany your appeal).
Seth Hyman says:
I’m working up an OCST program within a family practice group and am wondering what your take is on submitting claims using the following protocol.
1. ICD-10 G47.33 or other relevant diagnoses as defined in the LCD for our MAC
2. These two billing codes on every claim G0398 / 95806 indicating type II OCST
3. STOP-BANG score
4. ESS score
5. Note on the claim, as well as the patient’s file, indicating patient was educated on the use of home sleep testing by an R-PSGT credentialed sleep technologist and watched the 2108 AASM approved video presentation.
6. Evidence of raw data scoring and analysis by an R-PSGT credentialed technologist
7. Evidence of rendering parties ABSM credentialing and appropriate state license
I’m looking for suggestions on how to most clearly present the information in all of these points on a one page cover form with the patient notes, Dx/ Rx, surveys, raw data (tech’s scoring report), and interpretation on subsequent pages. And now that I think about it, I’m wondering if it is even necessary to include the technologists’s report. We’re looking to dial in the process here, and then apply for grants related to pediatric OCST. Any and all feedback is greatly appreciated
Dr. Kezirian says:
Honestly, you know much more about this than I do. When I order sleep studies (out-of-center testing and in-laboratory testing), the administrative team in my office obtains authorization. I get much more involved in authorization for procedures, where I will often speak with a medical director in a peer-to-peer discussion. Also, I primarily treat adults, so I am not familiar with the latest updates on pediatric OCST.
Cassandra White says:
Hello,I have been given by 2 doctors to have a in lab sleep study did.and my Medicaid deny the test to be done.But Medicaid said they will pay for a home study first.I am so frustrated to the point of no return.My doctor feel that I have sleep apnea but have to prove it.But how will I get the help I need if Medicaid dont pay for in lab sleep study.I already have major depression disorder, Chronic Migrane,Coronary heart disease risk,Kidney disease, kidney stone,Back spasm/Back Arthritis and all of this is affecting my life.I am 39yr old,And I have been bound by this since I was 8yr old.It has affected my social life. My business life,I am on duloxetine, and several other medicine who run my life.I just need the pain to stop and need the right treatment
Allison Harder says:
I was recently seen by an ENT who ordered a sleep study because of my loud snoring, tiredness, etc. and after a few weeks of waiting to hear if it was approved I called and they said it was and transferred me to scheduling. There I scheduled my sleep study and got it done a few weeks later. I was diagnosed with severe sleep apnea and said I needed a CPAP machine with a full face mask.
After a week or two I happened to look at my EOBs and it showed that my sleep study claim was denied. I called my insurance and they are insisting that they NEVER said my sleep study was approved even though the ENT office said it was.
Now what???
Dr. Kezirian says:
It sounds like you should raise this issue with the office that ordered it and should not be responsible for the cost unless you specifically said you would pay for something that was not covered by insurance.
Hector Quintero says:
Dr Kezirian, are there any sleep labs in California that can detect and score UARS as aggressive as Stanford?
Dr. Kezirian says:
Probably not quite as aggressively, but there are many excellent sleep centers that can score hypopneas based on arousals.
Jessica Rosario says:
I was diagnosed with mild sleep apnea 5 years ago, I lost my cpap machine two years after using it. I went to see my pulmonary doctor to request a machine cause I haven’t used the machine in years and my sleep is getting worse. Doctor requested a home sleep study were the results said I had 0 events happened. I only slept two hours that night. what can I do to get my machine back? I wake up gasping for air. I know i still have sleep apnea.
Dr. Kezirian says:
Your doctor can order an in-laboratory sleep study. Home sleep studies have many advantages, but an in-laboratory sleep study will be more likely to diagnose obstructive sleep apnea.
Nathan says:
Hi – I went through a lengthy process including a sleep study that determined I had sleep apnea (AHI 25) – waking up out of breath, extremely tired etc … every doctor I saw suggested orthognathic jaw surgery.
After a plan had been drawn up and surgery pencilled into the calendar, the insurance rejected coverage – even after a peer to peer. Ive now submitted records from other doctors that pointed to this being an option, as well as the sleep study and xrays making the case in conjunction with the appeal
From experience, what are the odds of an overturning? I’m primarily surprised that even after a peer to peer that this still got rejected which has me concerned…
Appreciate your thoughts
Dr. Kezirian says:
Keep going with your appeals. I do not have experience with overturning decisions about jaw surgery, but my experience with other appeals is that they work about 1/3-2/3 of the time, depending on the type of procedure.
Randi Westphal says:
Hi!
My 25 year-old daughter was diagnosed with chronic fatigue and fibromyalgia in 2017.
In 2019 her new doctor suggested a sleep study to see if CPAP might help.
The insurance company initially approved a sleep study, but then changed their mind; suggesting that her ‘fatigue’ was a pre-existing condition.
Is it worth challenging the insurance company?
Thank you in advance for your help!!
Dr. Kezirian says:
The restrictions on coverage for pre-existing conditions are much narrower now due to health care reform (commonly called Obamacare). You should confirm that this exclusion of care for pre-existing conditions is still in place, as it may be gone. Then your doctors should appeal/challenge the denial with you.
James Berry says:
I have severe sleep apnea. My machine is 17 years old and failing. I also have my class A CDL that requires that I am being treated for it. Try have also refused my appeal. What do I do to get them to accept it? Hire an attorney?
Dr. Kezirian says:
Everyone should be covered for a new CPAP machine every 5 years (in addition to refills on supplies every 1-6 months, depending on the supply). You may need a more-recent sleep study showing sleep apnea, but this should be very straightforward and not require hiring an attorney — or even the need to appeal the insurance company decision.
Ryan Fidler says:
I was referred to a hematologist after some blood work had elevated red blood cell counts. After eliminating a rare blood disorder and since I don’t smoke and am on no medication, the doctor was left with sleep apnea as the only likely cause. They set up the sleep study, did the sleep study, and now I’m being told my insurance won’t pay for it. The study was negative by the way leaving the doctor confused.
Dr. Kezirian says:
Typically they would obtain insurance preauthorization, but even without it, this is a common reason to order a sleep study. Keep fighting it. If the sleep center was supposed to get preauthorization but did not do that, then you may not be responsible for the cost.
Marsha Van Tol says:
I just got denied an inlab sleep study. They approved an at home sleep study. I have been using a CPAP since June 2000. I had a 2nd sleep study done in June 2011, approved because my machine was 10 years old. It came back severe apnea. Fast forward 2022, new insurance company. I noticed that my fitbit was registering Activity with heart rate up to 140’s while I am sleeping. I went away with my cousin for the weekend and she said I snored during the night with my cpap on. Consult with sleep doctor last week, he said there is something wrong and scheduled a sleep study. Denied by HAP. I have been told that a home study (which is approved) will not determine the source/cause of the heart rate/activity spike while sleeping. Home study will only say if I do or don’t have apnea. I do. This is ridiculous.
Dr. Kezirian says:
Home studies can be good for diagnosing sleep apnea if you have a high risk of having obstructive sleep apnea. I would generally recommend proceeeding with the home study and getting the in-lab study if the home study does not show obstructive sleep apnea.