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I have a patient who’s sleep dr diagnosed him as mild OSA. He does snore and his AHI is 4.3. Otherwise he is in good health, he just feels tired all the time and both his father and brother have OSA and use the CPAP. Will his insurance company not pay for his OAT since he is less than 5 with his AHI? I have informed that his medical may not cover this and I could make him a snoring OA, which would be an out of pocket cost.
Regards,
Ron Hayes
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Hi rhayes!
Great question. Generally the insurer will honor the diagnosis of the sleep physician rather than what the AHI is. (for example - some physicians and insurers will also consider RDI for the diagnosis of OSA, or if there are many/severe oxygen desats but the AHI isn't quite 5, the sleep physician may still diagnose OSA)
If you want to be sure, you can submit a pre-authorization to the insurer!
Hope this helps. Please feel free to contact us with any further questions
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 1 user thanked courtneydsnow for this useful post.
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WE had have similar case. In this case was female patient diagnosed with UARS (Upper airway syndrome)which is not apnea but if not treat will involved into sleep apnea. Oral appliance was paid by the insurance after 1 appeal, when you sent second sleep study an evaluation sleep scale that showed patient has improved. she got 5000.
HER AHI was under 5. but she present UARS
Hope this help
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1 user thanked Guest for this useful post.
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That's great Meily! Thanks so much for sharing! :)
Remember, this is a great example - not everything in medical insurance is written in stone! Appeals can do wonders!
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Rank: Guest
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