Sleep Apnea CPAP Insurance Denied: How to Appeal a CPAP or Sleep Study Denial

Sleep Apnea CPAP Insurance Denied: How to Appeal a CPAP or Sleep Study Denial

Obstructive sleep apnea (OSA) is a serious medical condition affecting millions of people worldwide. Untreated, it increases the risk of heart disease, stroke, diabetes, and accidents. Despite this, insurance companies regularly deny claims for sleep studies (polysomnography), CPAP machines, supplies, and related treatment — often on technical grounds that can be successfully appealed.

Why Sleep Apnea Claims Are Denied

Sleep study denied:

• Insurer argues home sleep test (HST) is sufficient instead of in-lab polysomnography
• Symptoms don't meet the insurer's threshold for a covered sleep study
• Prior authorisation not obtained
• Not performed at an accredited sleep facility

CPAP machine denied:

• AHI (Apnea-Hypopnea Index) doesn't meet coverage threshold
• Sleep study not conducted at an accredited facility
• Prior authorisation not obtained before CPAP was dispensed
• Provider credentials issue

CPAP not covered after trial period:

• Compliance documentation not submitted: Most insurers require you to use your CPAP machine for a minimum percentage of nights and hours per night during a 90-day compliance period. If the data doesn't meet the threshold, ongoing CPAP coverage is denied.
• Machine readings not transmitted to insurer or provider

CPAP supplies denied:

• Resupply frequency exceeds plan limits
• Documentation of ongoing use (compliance) not submitted
• Non-covered supplies (specific mask styles, accessories)

Alternative therapy denied:

• Oral appliance therapy denied as "experimental" or "not medically necessary"
• Surgical treatment (UPPP, inspire implant) denied

Medicare and CPAP Coverage Criteria

Medicare Part B covers CPAP therapy for OSA under specific criteria — understanding these is essential since many commercial insurers mirror Medicare's criteria:

Medicare CPAP Coverage Requirements:

1. Diagnosis from sleep study: OSA must be diagnosed by a sleep study (home or in-lab) conducted by a Medicare-qualified sleep facility
2. AHI criteria: AHI of ≥15 events/hour, OR AHI of ≥5 events/hour with documented symptoms (excessive daytime sleepiness, impaired cognition, insomnia, documented hypertension, ischemic heart disease, or stroke history)
3. Initial trial period: Medicare covers CPAP initially as a 3-month trial
4. Compliance: After 12 weeks, a treating physician must document that the patient is benefiting from CPAP (reduces symptoms, patient using the device)
5. Documentation: Compliance data from CPAP machine (typically 4+ hours/night on 70%+ of nights over 30 consecutive days during the 90-day trial)

If your CPAP was denied by Medicare or a commercial insurer using Medicare criteria, ensure your documentation meets all these requirements.

Step-by-Step: Appealing a CPAP/Sleep Apnea Denial

Step 1: Identify the Specific Denial Reason

Review the denial notice carefully:

• Is the sleep study denied (prior auth, facility accreditation, symptom threshold)?
• Is the CPAP equipment denied (AHI criteria, prior auth, sleep study validity)?
• Is ongoing CPAP coverage denied (compliance documentation)?
• Are CPAP supplies denied (frequency limits, compliance)?

Each requires a different approach.

Step 2: Gather Documentation

For sleep study denials:

• Letter from your physician documenting sleep apnea symptoms (snoring, witnessed apneas, excessive daytime sleepiness, waking headaches, non-restorative sleep)
• Prior authorisation approval (or documentation that PA wasn't required for your plan)
• Accreditation documentation for the sleep facility

For CPAP denial based on AHI:

• Complete sleep study results showing AHI, oxygen desaturation events, REM-related vs. NREM-related apneas
• Your physician's letter explaining clinical significance of the AHI findings in the context of your specific symptoms and comorbidities
• Documentation of hypertension, heart disease, stroke history (if using the AHI ≥5 with comorbidities pathway)

For compliance-based denial:

• CPAP machine compliance data (download from the CPAP card or online portal — most modern CPAPs like ResMed AirSense provide compliance reports)
• Documentation of any compliance issues and steps taken to address them (mask adjustment, pressure adjustment, chin strap use, etc.)
• Physician documentation of clinical benefit (symptoms improvement, daytime sleepiness reduction)

For ongoing coverage disputes:

• Compliance data showing 4+ hours/night on 70%+ of nights
• Physician attestation that CPAP is benefiting the patient

Step 3: Request Peer-to-Peer Review

For CPAP denials, requesting a peer-to-peer review between your sleep physician and the insurer's reviewer is often highly effective. Sleep medicine specialists can directly address technical objections about AHI interpretation or compliance requirements.

Step 4: Submit Your Formal Appeal

Your appeal letter should:

• Address the specific denial reason point by point
• Include your sleep study data, compliance data, and physician's letter
• Reference clinical guidelines from the American Academy of Sleep Medicine (AASM)
• For Medicare, reference the Medicare CPAP coverage criteria specifically and demonstrate you meet them

Step 5: Request External Review

After exhausting internal appeals, request external review. External reviewers apply clinical standards and are not bound by your insurer's internal criteria. For sleep apnea denials with strong clinical documentation, external review success rates are meaningful.

Step 6: Medicare-Specific Escalation

For Medicare CPAP denials:

• Level 1: Redetermination by Medicare Administrative Contractor (MAC) — 60 days to file
• Level 2: Reconsideration by Qualified Independent Contractor (QIC) — 180 days
• Level 3: ALJ hearing — 60 days from QIC decision (if amount in dispute > $180)
• Level 4: Medicare Appeals Council
• Level 5: Federal court

Oral Appliance Therapy Appeals

Mandibular advancement devices (MADs) are an effective alternative to CPAP for mild-to-moderate OSA, particularly for patients who cannot tolerate CPAP. If your oral appliance claim was denied:

• Most commercial plans and Medicare cover oral appliances when CPAP is contraindicated or cannot be tolerated
• Documentation of CPAP intolerance is key: physician's letter documenting failed CPAP trial, specific reasons for intolerance, and clinical rationale for MAD
• The device must be fitted by a licensed dentist with sleep medicine training and supported by a sleep study diagnosis

Inspire (Hypoglossal Nerve Stimulator) Appeals

Inspire (hypoglossal nerve stimulation) is an FDA-approved implant for OSA in patients who cannot tolerate CPAP. Coverage criteria are strict:

• AHI of 15–65 events/hour
• BMI ≤ 35
• Documented CPAP failure
• Adequate anatomy (excluding certain airway configurations)
• Prior evaluation by ENT physician

If your Inspire claim is denied, ensure all coverage criteria are meticulously documented in the appeal.

Conclusion

Sleep apnea CPAP and treatment denials are frequently based on missing documentation — sleep study validity, compliance data, or physician documentation — rather than genuine clinical ineligibility. Ensuring your documentation is complete and meets the insurer's specific criteria resolves most appeals. For complex denials, escalate to external review and peer-to-peer review. Use ClaimBack at claimback.app to generate a professional appeal letter for your sleep apnea treatment insurance denial.

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Related Reading:

• How to Negotiate with Your Insurance Company
• How to Write a Second Insurance Appeal Letter
• How Long Does an Insurance Appeal Take?
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies