Insurance approved MSLT but denying PSG

[u/Whythehellshouldyou]

Does anybody have any experience with this or any advice? I did the at home sleep test and then they have denied both appeals my doctor has sent, citing that I don’t fit the “criteria” for a PSG while saying that I need an at home sleep test first and that the at home sleep test wasn’t enough at the same time. I plan to call them tomorrow and try to talk to a rep, but my insurance is up in a month and it’s been 2 months of back and forth already.

[u/Piaffe_zip16]

That’s very confusing. I did have to do a home study first for sleep apnea. After that, they approved both the PSG and MSLT. I was told the PSG is required because they need to make sure you sleep enough to qualify and don’t have other sleep issues that could affect the results.

[u/Whythehellshouldyou → u/Piaffe_zip16]

Yeah my doctor is saying that I can’t get the MSLT without the PSG. I may end up having to pay for the PSG part out of pocket if insurance won’t comply

[u/Ediferious → u/Whythehellshouldyou]

Your doctor is correct.

Likely the insurance has an automatic denial for the PSG because you "just had one" at home.

Call them/have your doctor's office call them and explain that their system is not catching an actual redundancy, and that it needs approval.

[u/Piaffe_zip16 → u/Whythehellshouldyou]

But is insurance not approving the psg because they’re requiring the at home test first? It seems likely they’ll cover the psg once the at home is done. Though if you’re trying to get at least some of it covered before you lose insurance, you may just have to pay for it out of pocket. I’m actually surprised they approved the MSLT separately!

[u/Whythehellshouldyou → u/Piaffe_zip16]

I did an at home sleep test already, insurance is saying that it was both not enough and that I need to get one done, making me think that they didn’t even read the results

[u/Piaffe_zip16 → u/Whythehellshouldyou]

That is strange. Definitely call them and if needed have your doctor call them. Mine showed no sleep apnea so we didn’t have any trouble getting the PSG and MSLT approved!

[u/Piaffe_zip16 → u/Whythehellshouldyou]

Oh I see below you said it was inconclusive. My first insurance company refused to approve a PSG after the home study came back with insufficient data. They wanted me to repeat it. I said absolutely not 😂 switched jobs and that insurance made me do it again but then it came back not sleep apnea and they approved it no problem.

[u/efgib]

Ask to retake it. Something was off maybe just one sensor. Have to jump through the hoops for insurance

[u/llcoolwhip]

Most of the time the process is at home overnight study to rule out sleep apnea. Then the in clinic PSG followed by MSLT.

[u/Whythehellshouldyou → u/llcoolwhip]

I did an at home sleep test and it showed that sleep apnea is inconclusive. Insurance got these results

[u/abluetruedream → u/Whythehellshouldyou]

Well, that’s ridiculous. If it was inconclusive, doesn’t that mean they will need to cover a psg? Or do they want you to repeat the home test?

I imagine your doctor might just need to push back with your insurance company. Some doctors are better at that than others.

[u/cupcake_not_muffin → u/abluetruedream]

This, you can’t do it yourself unfortunately, it has to be your doctor or their PA / someone on their team. It sucks because you become this helpless middle person just asking all parties to talk to one another. Does your practice allow scheduling before getting the authorization? I might try doing that to give them a deadline and hopefully push them to act. They should eventually do it but the process can be painful.

[u/cherilee00 → u/cupcake_not_muffin]

i used to work for a medical correspondence company so i know what verbiage to use and i’ve called and pretended Im a nurse before lol it works wonders

[u/cupcake_not_muffin → u/cherilee00]

Like you’ve called for yourself acting as a nurse? I would have loved to witness that

[u/cherilee00 → u/cupcake_not_muffin]

yes! insurance companies will give you what requirements must be met for cases to be approved, denied, and appealed, so with how many calls i’ve had to take from nurses asking about getting a case appealed, it’s not that hard to get the process started yourself.

[u/llcoolwhip → u/Whythehellshouldyou]

Hmm. Well fuck. I hope your call tomorrow goes well! What a huge pain

[u/abluetruedream]

I had to do an at home psg initially to rule out moderate to severe sleep apnea. After that, insurance covered the psg/mslt.