Sleep study not medically necessary?

[Kellyann86 2]

I started the process for the sleeve surgery last month. I started my nutrition classes and my next step is to have a sleep study done. However, I just received a letter from my insurance company stating that they don't believe a sleep study is medically necessary so they won't cover it. I'm worried that this will prevent me from having the surgery. Has anyone else not been required to have the sleep study and still got the surgery?

[KristenLe 5,979]

If you have any snoring, hypertension, depression, fatigue then they should cover it.

[Kindle 8,667]

Unfortunately in the US the insurance companies like to decide what is or isn't medically necessary, not the doctors. So if they aren't requiring that you get it and your surgeon isn't requiring it, then don't worry about it. If your doctor feels it is medically necessary before going forward with surgery then his office should appeal the insurance company's denial. And if they still deny it then pay for it yourself.

I've forked out thousands and thousands of dollars for medical procedures that were, indeed, necessary but insurance wouldn't cover. My doctor and I care about my well being even if insurance doesn't (which, BTW, is the LAST thing they care about)

Sorry, rant over.

[Momma_of_3 2]

You can appeal it to your insurance company. You can also request your surgeon to appeal the decision with your surgeon.

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[kmorri 1,689]

My guess would be that the authorization request that the doctor submitted didn't document any conditions that warranted having a sleep study......there are specific medical requirements necessary (that are determined by sleep disorder specialist) for an insurance company to pay for a sleep study......if your doctor believes a sleep study is medically necessary then they need to ensure the medical condition that warrants the sleep study is documented in their auth request. .....I worked with BCBS for 29 years. The medical policy that insurance companies follow is not something they just make up in order to not pay claims.....These policies are developed by doctors that specialize in whatever the policy covers.....When something is denied when it is actually medically necessary most often it's because the patients condition is not properly documented in the records provided to the insurance company by the doctor....

I am in no way saying insurance companies don't make mistakes because Lord knows they do!!! But insurance companies don't just deny medically necessary covered services for no reason.

[BBweightlossjourney 49]

I started the process for the sleeve surgery last month. I started my nutrition classes and my next step is to have a sleep study done. However, I just received a letter from my insurance company stating that they don't believe a sleep study is medically necessary so they won't cover it. I'm worried that this will prevent me from having the surgery. Has anyone else not been required to have the sleep study and still got the surgery?

@@Kellyann86

Call your Doctor Monday and inform him of the refusal . I was told if the Sleep study isn't approved for any reason, then you get to do a take home sleep study, which in my opinion the best because you can do it in your home . I hated the Sleep study and the facility I had to go to. The doctor is used to some patients being refused and so they are prepared with options such as the take home test.

All the best !

[Sajijoma 1,324]

My insurance said a sleep study wasn't needed and my surgeon didn't fight it. He just screened me based on my snoring and waking up choking and made sure they watched me carefully as I was waking up so I didn't choke. They actually left my breathing tube in until I woke up completely because of the risk that I did have it.

[sgc 538]

I didn't need a sleep study for this surgery but I did need a sleep study in the past. My cardiologist wanted me to have one but she couldn't order one. My insurance wanted it order from a pulmonary specialists so she set up with one who ordered it and insurance covered it.

[Kellyann86 2]

Thank you all. I'm going to call my surgeon on Monday and see if they really need it. If so, I did see something on the letter about a home sleep study.. So maybe I can do it that way if they think it's still necessary. I don't have the money to pay out of pocket for it. I feel much better now though! I've been waiting a long time for this surgery so receiving that letter was disappointing. I'm just hoping it won't stop me from having the surgery!

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[Valentina 2,642]

Do you have sleep apnea? If you don't have it, maybe you don't need a sleep study.

I didn't have a sleep study, because I've never suffered from sleep apnea.

​"If it ain't broke, don't fix it".

Good luck.

[Kellyann86 2]

Nope. No apnea, no snoring, no heart condition. That's why my insurance doesn't think it's medically necessary. I'm hoping my surgeon doesn't feel it's necessary either.

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[Momma_of_3 2]

I will just say that snoring does not equal sleep apnea. I do not snore, my husband never noticed any issues while I slept yet I was diagnosed with severe obstructive sleep apnea.

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[Kendell Thatsme 39]

I am in the process of getting the sleeve and i was told because i am overweight and snore it was a requirement Took my sleep study Saturday while someone who had they surgery in the same location who was also overweight and snore didnt need it. So i don't understand how that goes.

[Madea61 27]

I started the process for the sleeve surgery last month. I started my nutrition classes and my next step is to have a sleep study done. However, I just received a letter from my insurance company stating that they don't believe a sleep study is medically necessary so they won't cover it. I'm worried that this will prevent me from having the surgery. Has anyone else not been required to have the sleep study and still got the surgery?

I am going back and forth with my PCP to send the information to my insurance company so that I can have the sleep study done. When I talked to my insurance company they said that the only thing they are waiting for is the medical codes for the sleep study.

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If you have any snoring, hypertension, depression, fatigue then they should cover it.

Ok

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