(02-05-2013, 05:05 PM)theosgirl45 Wrote: I was recently diagnosed with sleep apnea and my insurance has decided that they aren't going to pay for my machine.
Maybe I'm stating the obvious, but I'm pretty sure that unless you have only very basic "Major Medical" coverage, most private health care plans do cover CPAP, albeit at different levels and costs to you as the patient (with regard to deductibles, co-pays, and other limits etc). If they covered your overnight sleep study, it's likely that they will also cover CPAP.
Not sure who told you that your insurance policy would not cover CPAP, but it may be worth it to go to someone "higher up" or to look at your policy documents directly to see if what you are being told is "the whole truth" with regard to coverage for "Durable Medical Equipment" like CPAP.
But again, if it's a simple policy meant only to cover major medical events, they may be correct in what they told you.
When I had private insurance, many times I would get two completely different answers on a coverage issue, depending upon who I was talking to on the phone. But what really matters is your written policy terms (insurance contract), not what someone "told you" over the phone.
That said, keep in mind that many insurance companies have a habit of training their phone reps to tell you "Sorry, you're not covered for that" (when you contact them at first). There is no law that says they must be completely honest with you over the phone. What matters is the insurance contract, not a verbal conversation. Also, if you do decide to challenge them or appeal their 'decision', they make the whole process complicated on purpose-- it's designed that way to frustrate you into giving up (so that they can reduce their costs). Many times you have to be very persistent.
In addition, insurance companies may require you to submit a doctor's "Certificate of Medical Necessity" in order for them to pay for CPAP. Many times "borderline sleep apnea" is not sufficient enough to warrant a "medical necessity". A sleep study that determines an untreated AHI (Apnea Hypopnea Index) of less than 15.0 is often enough to be considered "borderline OSA", resulting in a denial for CPAP. Some insurance companies may set that limit slightly lower or higher, so you'll need to ask them at what point on the AHI scale do they consider CPAP to be a medical necessity, and also ask if there are any other criteria they use to determine coverage.
Apnea Board Administrator