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  • Insurance denied CPAP

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    Old 11-15-2002, 08:27 PM   #1
    DDLyon
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    Question Insurance denied CPAP

    Hi,
    I was recently diagnosed with Sleep Apnea. Today I learned my insurance company denied the CPAP as not being medically necessary. Other than the doctor sending a letter of Medical need what else do I need to do to get the machine I need.

    Has anyone else run into this? Does anyone know what the criteria is to establish medical need? This whole thing has been a nightmare. From a doctor who's only contact with me was through his receptionist who called and said "Yeah you have Sleep apnea go back to the same place to do the second test - so I don't have to do any more paper work" And now an insurance company who thinks the specialist who read my sleep study results did not show medical need. I'm very frustrated.

    BTW - there were two Doctors who wanted the sleep study - the second one has jumped in - gave me results and is doing whatever necessary to get me the machine. Is there anything else we have missed? Thanks in advance for any help you can give!

     
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    Old 11-16-2002, 12:30 AM   #2
    Esoteric
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    I think that when an insurance company denies coverage of something like a CPAP, you need to appeal the decision. Usually it's more red tape for your Doctor. I would imagine that if you had enough episodes with a lowered oxygen reading, your Doctor would help you with the appeal. Call the insurance company and ask how to appeal.

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    Old 12-04-2002, 07:05 PM   #3
    Doppelganger
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    I'm the CFO for a sleep diagnostic company, and so know something about this. First, insurance companies are in the business of denying coverage, so keep trying. Second, most insurers have nurses reviewing for medical necessity who are woefully uneducated about sleep disorders - insist that an MD review your case. Lastly, many companies have a minimum RDI (Respiratory Disturbance Index) to qualify for CPAP therapy. The most common minimums are 15 or 20, although RDI's as low as 5 may qualify depending on oxygen desaturation levels. If your RDI is below your insurer's minimum, you may have a tough time - but, then again you may not really need CPAP either. Physicians interpreting sleep studies are frequently biased toward CPAP therapy, and if your RDI is low you should look into dental appliances or changing sleeping positions before beginning CPAP therapy.

     
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