What to Do if Your Claim Is Denied

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Having your CPAP insurance claim denied can be frustrating, but it doesn’t always mean you’re out of options. Many denials happen because of missing documentation, incorrect billing codes, or unmet coverage requirements that can often be addressed with an appeal or additional information.

Below, we’ll explain the most common reasons a CPAP insurance claim may be denied and how to appeal a denial to try and receive coverage.

What Does It Mean When a CPAP Claim Is Denied?

When a CPAP claim is denied, it means a health insurance company has decided not to cover a person’s CPAP therapy and will not pay any part of the cost of CPAP equipment or supplies. A denial differs from a pending claim or a rejection.

Pending claim: A pending claim has been received but not fully processed, either because it was just recently received or because the company needs more time to review details of the claim. Missing or incorrect information can lead to a claim maintaining a pending status for a longer period of time.

Rejected claim: A rejected claim hasn’t been processed because of technical errors or missing information, like an invalid code, incorrect formatting, or incomplete patient information. Once the needed information has been received or corrected, the claim can be processed.

Denied claim: A denied claim has already been processed, and the insurance company has determined that the policy doesn’t cover the claim. A denied claim can be reconsidered only if it’s officially appealed. In contrast, pending and rejected claims do not require an appeal to be considered, because they haven’t been processed yet.

Denial notices must be sent to you in writing. If you receive a denial notice, you can file an appeal within 6 months of receiving the notice. If you wait longer than that, you won’t be able to appeal the decision and won’t receive coverage.

Common Reasons CPAP Insurance Claims Are Denied

Denials are fairly common for CPAP equipment, for multiple reasons often related to errors either in care or documentation.

Missing or Invalid Prescription

CPAP equipment requires a prescription and cannot be legally sold to someone without one. If an insurance company doesn’t receive documentation of the prescription, or if the prescription sent over contains incorrect or missing information, insurers may deny the claim.

Lack of Medical Necessity

To establish that a person has sleep apnea and needs CPAP therapy, two things must happen. First, there must be an appointment with a sleep specialist to discuss symptoms and medical history. Second, the person must undergo an in-lab sleep study or at-home sleep apnea test to establish symptoms.

Insurers may deny coverage if they don’t receive evidence a person had a meeting with a doctor before their sleep test. Some insurers may also deny coverage if a person didn’t have an overnight, in-lab sleep study as part of their diagnostic process.

Lack of CPAP Therapy Compliance

Sometimes insurance companies cover CPAP therapy initially, then deny coverage later, because a person doesn’t use their machine enough after receiving it. CPAP compliance, also called adherence, is defined as using a CPAP machine for an average of four or more hours each night, 70% or more nights during each 30-day period, throughout the first 90 days after receiving a machine.

People who use their machines for less than this amount of time will lose insurance coverage, which is why it’s important to attend follow-up appointments to troubleshoot any problems that arise. Even if a person does use their machine the amount required, they could have coverage denied if they don’t have a follow-up appointment to discuss CPAP therapy within the first 90 days after beginning it.

Incomplete or Incorrect Documentation

Sometimes a person has gone through the necessary steps but still receives a denial of coverage, because the proper documentation wasn’t submitted to the insurer. For example, if accurate prescription, doctor appointment, sleep study, or compliance data documentation aren’t received by an insurance company, they may deny coverage.

Out-of-Network Supplier

In other cases, an insurance company may deny coverage because of the supplier a person bought their CPAP equipment from. Many health insurance companies have specific suppliers they will work with and maintain a list of these covered durable medical equipment (DME) providers. Any businesses selling CPAP equipment that aren’t on their list won’t be covered.

Coverage Limitations or Exclusions

Insurance providers may have limitations or exclusions that apply to CPAP therapy. For example, they may have strict criteria regarding the diagnosis of obstructive sleep apnea, with requirements that supersede those your sleep specialist uses. They may also place limitations around the type of CPAP machine you’re able to receive coverage for, as well as how often you can receive coverage for new accessories.

What to Do After a Claim Is Denied

Although it can feel frustrating to receive a claim denial, you have options. A denial doesn’t necessarily mean you can’t have your CPAP equipment and accessories covered. Follow these steps to figure out the best way to proceed when you receive a denial.

1. Review the Denial Notice Carefully

Closely read through your claim denial notice, and consider having another person read it over to make sure you’re understanding it. Health insurance companies are legally required to outline why your claim was denied. They also have to provide details about how you can submit an appeal, when your appeal deadline is, and whether or not there is a Consumer Assistance Program available to help you in your area.

2. Contact Your Insurance Provider

Reach out to your insurance company by calling a phone number listed in the denial notice, if there is one. If not, call the phone number listed on the back of your insurance card. Explain that you received a denial notice, and talk about the details of the situation to confirm that you understand why your claim was denied. Ask any questions you may have until you feel like you understand what needs to be done to move forward.

3. Contact Your CPAP Supplier or Doctor

Depending on the reason your claim was denied, your next step will likely be to call either your CPAP supplier or your sleep specialist. Explain clearly that your claim was denied and the reason for the denial. Ask for their help in appealing. One or both parties may need to send over missing paperwork, add missing information to existing paperwork, or correct errors in existing paperwork in order.

4. File an Appeal

Now, it’s time to file your appeal, which is also called an internal appeal, because it stays between you and the insurance company. Filing an appeal involves following the instructions your health insurance company provided in the denial notice.

Generally, you must fill out and submit an appeal form, whether in print or online, to begin the appeal process. You may also need to write a letter. Be sure to explicitly state that you’re appealing your health insurer’s claim denial. Include your full name, your claim number, and your insurance ID number in your appeal paperwork. Don’t forget to file the appeal within 6 months of receiving the claim denial.

How to Improve Your Chances of a Successful Appeal

Many states have Consumer Assistance Programs (CAPs) that employ people who can help you with your denial appeal at no charge. The Consumer Assistance Program webpage allows you to look up what resources may be available in your state. Having CAP help with your appeal can improve its chance of success, since CAP employees are familiar with how the process works.

If you don’t have CAP resources in your state, that doesn’t mean you cannot successfully appeal on your own, however. Read over all instructions carefully, more than once, and make sure you follow them exactly. Consider having another person double-check the instructions, as well as your forms and letter before you submit them. Try to submit your appeal as early as possible, instead of waiting until the last minute.

What if Your Appeal Is Denied?

In some cases, if you have health insurance sponsored by your employer, you can submit a second appeal if your first appeal is denied. This process would work similarly to the first appeal process. Before filing a second appeal, you would want to talk with your health insurance company again to gain clarity on why the appeal was denied and what would need to be in place in order for it to be approved.

Some people cannot file a second internal appeal, but they can choose to file an external review if the first appeal is denied. Those who file two appeals and have both denied can also opt to file an external review. An external review is a right under the Affordable Care Act, and the process brings an outside party into the situation. You can learn more about who qualifies for an external review and how to file one through the External Review Process website. You can also ask someone, like your doctor or sleep specialist, to file the external review for you, if they believe the denial was incorrect.

If your external review doesn’t work out in your favor, or you don’t want to go through the external review process, switching suppliers could be a good idea. Some online CPAP shops offer low prices and payment plans or rental options that can make CPAP therapy more affordable for you, even without health insurance coverage.