I’m looking for advice about a sleep study that my insurance denied. My sleep doctor, who I’ve been seeing for over a year, had requested a 2-part sleep study for me. The lab scheduled it, but later, I got a call saying the authorization for my appointment was denied by my health insurance (Cigna Open Access Plus).
I called my insurance to ask why it was denied and what I could do to get it approved. They told me my doctor could do a Peer-to-Peer review with them to try to get it authorized.
My doctor contacted them but was told I don’t have enough symptoms to justify the sleep study. We discussed my symptoms, but unfortunately, they didn’t accept it.
Is there anything else I can do to get this study authorized? I really can’t afford to pay for this out of pocket.
Before filing an appeal, see if they might want you to try a home sleep test first. Some insurance companies require an at-home study before covering an in-lab one.
Tan said:
Before filing an appeal, see if they might want you to try a home sleep test first. Some insurance companies require an at-home study before covering an in-lab one.
Interesting! Did they tell you that information right in the initial denial? Wondering how I’d know if they require a home study before the lab one. Thanks for the tip!
@Morgan
I’m not sure, my doctor just checked with her prior auth team if my insurance needed a home study first and they said yes, so we did it that way. Maybe ask your doctor to try ordering the home one and see if that gets approved?
Usually, you need to do a home test first before they’ll approve the more costly sleep study. Many people find the home test is enough for diagnosis and treatment. If your doctor thinks the in-lab study is necessary, they can appeal based on your home study results.
Insurance companies often require you to try less invasive or lower-cost options first, so this is pretty standard.
@Keir
Makes sense! The only issue is my study is overnight and during the day for narcolepsy testing, which I don’t think the at-home test covers. Maybe I could do the home study for the overnight part and do the lab study for the daytime part?
You should definitely appeal. They’re supposed to send you a denial reason in writing, along with instructions on how to file an appeal. You usually have three internal appeals and then a chance for an external third-party review. They might just say it’s not medically necessary, but you can also request the policy that lists the criteria for coverage.
Your doctor should ideally lead the appeal process, but you can handle it too if needed.
@Amari
Got it, thanks! I’ll check for the written denial and see if there’s clear info to use in my appeal. I’ll also ask for the policy to reference in the appeal.