Fighting with Insurance Company

[theMezz]

I am covered under two Excellus Family Plans.

They paid all my Doctors but refuse to cover CPAP and supplies.

Because of a faulty machine, waiting for appointments and a 2nd sleep study - my 1st 90 days of use was under 4 hours a day.

My 2nd 90 days is use EVERY night with a median of 8 hours a night.

Insurance will only look at the data form 1st 90 days which does not meet the usage requirements - so they deny coverage on CPAP as well as supplies.

I appealed and lost and now in NYS I can appeal again to an outside agency (in process of doing that)

If all fails I will just pay out of pocket - what choice do I have.

Tons of documentation from the sleep clinic, but all they will look at is data from 1st 90 days of use.  Equip provider will not acknowledge the 1st CPAP was defective and maybe it was not.  CPAP #1 and CPAP #2 both Airsense 10 with different firmware. CPAP#1 caused an increase in Apeneas , but CPAP#2 works.

According to CPAP provider the in company decision is valid for 7 months and they will not look at any other data until 7 months have past. By then I will own the CPAP.

Ins companies have it all figured out

[Sleeprider]

Good luck with your appeal. I think ensuring you have a CPAP machine that you are using is a lot higher priority than the policy and procedures of your insurance company, but it seems they write their own rules. The only alternative in paying out of pocket is to get the best price possible. Supplier #2 is offering your machine at $749 new, and you can find new and used deals on Craigslist for less.

[MitchS]

Sorry to hear about your trouble with your insurance company. They do have charging the max and paying the least down to a science.

Have you gone through their appeals process? I’ve had to do that twice over the years with employee plans. I ended up filing an appeal with the company administrators of the plans. In both cases the administrators intervened on my behalf and the insurance company’s decision was reversed. The appeal needs to be in writing. It needs to contain all pertinent information including any extenuating circumstance and any harm that will be caused by the denial.

Good luck.

[SuperSleeper]

Moving this thread from Off-Topic to the Main Forum since it's CPAP-related.

[theMezz]

Sorry to hear about your trouble with your insurance company. They do have charging the max and paying the least down to a science.

Have you gone through their appeals process? I’ve had to do that twice over the years with employee plans. I ended up filing an appeal with the company administrators of the plans. In both cases the administrators intervened on my behalf and the insurance company’s decision was reversed. The appeal needs to be in writing. It needs to contain all pertinent information including any extenuating circumstance and any harm that will be caused by the denial.

Good luck.

Appealed but denied
Going to do a 2nd appeal with outside agency (NYS)

[Gideon]

We may be able to help you "frame" your appeal.  We would need to see a full copy, not just the summary, of any and all Sleep studies that you have had..  Seeing your Sleepyhead charts would also be a big help.  See my signature for the how to do it.