Insurance Coverage for Sleep Studies, Sleep Apnea and CPAP

Quick answer: most commercial insurance plans and Medicare cover sleep studies and CPAP therapy when ordered by a physician for documented symptoms. CPAP coverage usually requires a positive home sleep test or in-lab polysomnogram and a physician order. Ongoing CPAP coverage usually requires adherence documentation -- Medicare specifically requires the patient to use CPAP at least 4 hours per night on at least 70 percent of nights during the first 90 days to qualify for continued coverage (CMS LCD L33718). Commercial plans typically follow similar rules. The most common reasons coverage is denied are missing prior authorization, no documented physician order, or adherence below the threshold. Advanced Sleep Medicine Services verifies your specific plan before the test ships and handles prior auth at intake.

Diagnosing and treating a sleep disorder is pivotal to your health and well-being. That being said, the process of getting the necessary treatments and diagnosis can make patients apprehensive if they do not know the costs that are ahead. Health insurance can be complicated, especially when it comes to understanding a new-to-you treatment like CPAP therapy. Today, we will talk about what you can do to save money, how to get good treatment and how to work with your insurance to cover the costs.

Getting Diagnosed: First Steps

Many are surprised to learn that they cannot buy a CPAP machine without first getting a prescription for one from a doctor. Many doctors use a home sleep test, followed by a prescription for auto-CPAP if indicated, as the primary pathway for addressing obstructive sleep apnea. A visit to the doctor is the first step in getting your diagnosis.

You are going to need to make an appointment with your doctor to discuss the symptoms you are experiencing that lead you to believe you may have sleep apnea. Some common symptoms of a sleep disorder are:

• Fatigue
• Depression
• Snoring
• Irritability
• High Blood Pressure (1)
• Sexual Dysfunction
• Lack of Concentration

If your doctor believes you are presenting symptoms of a sleep disorder, they will refer you to have testing done to confirm and diagnose the root cause. It will likely be an option of two different tests, depending on your needs. It would likely either be an at-home sleep test or an overnight study in a sleep center. If you want specifics on the differences between the two, click here. These are the different types of sleep tests performed:

1. In-Center PSG (Polysomnography) - The general sleep study/baseline
1. Split Night PSG (50/50 or Split)
1. Titration Study
1. HST (Home Sleep Test)
1. MSLT (Multiple Sleep Latency Test)

Once your results are in, your doctor will meet with you to discuss the course of treatment best suited to your needs. If it is deemed medically necessary, you should be authorized to have some coverage for a CPAP machine.

How Your Doctor Can Help Keep Costs Low

Unfortunately, out of pocket expenses are on the rise, but there are certain steps your doctor can take to help keep costs low. However, it’s important to remember that in the long run, it can cost less to make the investment in your health now than be faced with the expensive outcome of untreated sleep apnea.

Your doctor will suggest whatever treatment option they think is best for you regardless of cost, as this is the proper standard of care. However, they often will discuss alternatives with you including cost considerations to help ensure that treatment fits within your budget. For example, an at-home sleep test is going to be less expensive than staying the night at a sleep center. If you are a good candidate for an at-home test, this will be an option to try.

If you are showing mild symptoms of a sleep disorder, treatment options may include lifestyle changes like adopting a healthy diet or quitting smoking. Both of these are low cost and free.

If you do have OSA and require a sleep machine, your doctor may be able to recommend lower cost items and may stress the importance of compliance in order for insurance to keep paying their contribution.

How to Work With Your Insurance Provider

Each person’s insurance plan can vary, so it’s important to know how to work with your provider.

HMO

An HMO stands for Health Maintenance Organization. They have their own network of providers in which they provide coverage. Usually your doctor requests the service to be provider, and your medical group or HMO authorizes the service to a specific provider. Your doctor can often request a particular provider as long as that provider is contracted with your medical group or HMO. You get a copy of the authorization that shows the authorized provider contact information and you contact the provider for service. If you choose a provider outside of this network, you will pay a substantial amount more. Once your insurance has been properly authorized, you can receive the sleep study or CPAP device. Deductibles and co-payments may still apply.

Medi-Cal HMO

This is health insurance coverage with Medi-Cal the underlying coverage. (Medi-Cal is the Medicaid program in California). Medi-Cal HMO medical groups include HealthCare LA and Global Care. Medi-Cal HMOs work similarly to other HMOs. A typical process is that you visit your doctor to discuss your sleep symptoms, and your doctor orders a home sleep test followed by auto-CPAP if indicated.

PPO

PPO stands for preferred provider organization. Patients usually have greater choice within a PPO compared to HMO and can choose among a variety of in-network or out-of-network providers. However, most PPOs require prior authorization for sleep studies and CPAP devices. For CPAP and related supplies, many PPOs follow the Medicare usage guideline of using the CPAP at least 4 hours per night on at least 70 percent of nights during each 90 day period to qualify for continued coverage. Your out of pocket expense will vary depending on which plan you have, but most PPOs offer some form of coverage or another for the machine and supplies. Deductibles and co-payments may still apply. At Advanced Sleep Medicine Services, we usually handle the prior authorization process for PPO patients for home sleep tests. Your doctor should send us the order, progress notes, patient demos and patient insurance information, and we contact the PPO for authorization.

Medicare

Medicare is a federal health insurance program for those 65 and older. Medicare will also require authorizations for both sleep studies and a CPAP machine. If you have been diagnosed with sleep apnea, Medicare will allow a three month trial period of CPAP therapy. This trial will be extended if you are able to say the therapy has helped you and that you have been compliant. These factors can be dependent on the cost.

Often, many insurance companies will rent out the equipment on a monthly basis. These are the basic terms followed:

• 3-month rental, 4th-month purchase (many PPO insurances)
• 10-month rental (most typical option - most HMO insurance and some PPO insurances)
• 13-month rental (Medicare and other government insurance)

Call your provider to see what options are available to you and what your potential financial responsibility may be. Furthermore, it’s important that when and if you get coverage, you are compliant with your CPAP treatment. This means utilizing therapy for four hours each night. If your insurer does not see improvement in your symptoms or that you are not utilizing the device as prescribed, it is likely not going to be covered any longer. These are some reasons it can be taken away and why it is so important to remain compliant with your health and treatment.

The Importance of Treatment

It’s understandable to have concerns about paying for a diagnosis and treatment. Unfortunately, taking care of yourself isn’t always synonymous with low cost. However, to not take care of treating your sleep apnea results in costs that are too high to pay, financially, emotionally and physically. Untreated OSA is associated with early onset of dementia, heart attacks (2), strokes and diabetes (3). These extreme cardiac events and diseases can cost more long term than it would cost to treat sleep apnea, potentially preventing or eliminating the issues altogether.

As we all know, insurance cannot go overlooked when it comes to a health concern. Contact us for more information on your coverage for sleep studies today!

1. Phillips, B. (2008). Prevalence of Symptoms and Risk of Sleep Apnea in the US Population: Results From the National Sleep Foundation Sleep in America 2005 Poll.Yearbook of Medicine,2008, 319-321. doi:10.1016/s0084-3873(08)79227-7
2. Journal of the American College of Cardiology, August 2008, “Sleep Apnea and Cardiovascular Disease”.http://www.onlinejacc.org/content/52/8/686
3. “The Link Between Sleep Apnea and Diabetes.”/the‐sleep‐blog/the‐link‐between‐sleep‐apnea‐and‐diabetes/