Health insurance: covering an excluded condition?

May 13, 2013 2:20 PM

Can I convince my health insurance company to cover treatment for a condition my policy specifically excludes?

I've been diagnosed with a condition (sleep apnea) that, insanely, my health insurance policy (PacificSource) explicitly doesn't cover.

The folks in the doctor's office suggested appealing for coverage on the basis of "medical necessity." The doctor said he'd even write a letter to this effect.

Is there any chance in hell that could work? I mean, honestly, without treatment I'd eventually cost them more money from other domino health effects, right?

If so, how should I go about it?

posted by gottabefunky to Health & Fitness (11 answers total)

Won't hurt to try. My brother had what basically amounted to a rhinoplasty due to some severe sinus issues. His doctor/surgeon wrote a letter to his insurance, and they covered it, minus some specialist fees. This was BlueCross, however, so YMMV.
posted by Verdandi at 2:33 PM on May 13, 2013

Is this a personal (i.e., non-group) policy?
My understanding of the ACA is basically that insurers won't be able to exclude pre-existing conditions after 1/1/2014, so if this isn't immediately life-threatening, it may be better just to wait.
posted by Oktober at 2:35 PM on May 13, 2013

I paid accident claims for over five years, not sickness. Insurance coverage can very much be a case of "the devil is in the details." It also may be that your policy says one thing and state law says another. Assuming you are in the U.S., you could call your state's Department of Insurance and talk to them. They exist to look out for the consumer, not the insurance industry.

Linky where you should be able to find info on your state's dept of ins.
posted by Michele in California at 2:48 PM on May 13, 2013 [1 favorite]

If this is a group policy through your employer, and your employer is large enough to have one, go have a chat with the benefits specialist in your HR department.

They might actually have the ear of your insurance company and may, (if said manager is especially awesome) threaten to take their business elsewhere next open enrollment season.
posted by fontophilic at 3:01 PM on May 13, 2013

If there's a rider that your company would have had to add to the policy you can appeal but you may be out of luck. Most group insurance policies for small business often don't pick up "exotic" riders (weight loss surgery, sleep studies) so the best you hope for is paying it out of pocket and getting something back come tax time.
posted by playertobenamedlater at 3:27 PM on May 13, 2013

Often, it's the employer that specifies what procedures are and are not covered in a plan, I presume to make their negotiated rates cheaper. If this treatment is excluded from coverage, you may want to try HR.
posted by zippy at 6:28 PM on May 13, 2013

Response by poster: Sorry, should have added that this is an individual policy.
posted by gottabefunky at 8:12 PM on May 13, 2013

I would return to your doctor's office (neurologist? pulmonologist?) and get them to do this. That's what many doctor's offices have to do: Write letters of medical necessity. Have peer-to-peer conference calls with insurance company MDs. Etc.

If it's a decent office with a decent billing staff, they should be well-versed in this and able to do most of this for you.

You contacting your insurance company about these issues USUALLY ends in nothing but frustration.
posted by kuanes at 5:24 AM on May 14, 2013

Most health insurers cover a CPAP for sleep apnea. It's a one-time expense, not a continuing one. I've gotten several CPAPs over the years, and my insurance (admittedly group coverage) has always paid. Medicare certainly pays, and also Medicaid if you're eligible.

Your insurer will undoubtedly ask for additional payment to waive the sleep apnea exclusion. It may well be worth the cost of around $1,000 to buy a CPAP yourself. (You'll need a prescription.) I use a Respironics variable pressure machine with all the bells and whistles, and I couldn't live without it. And my wife has threatened to leave me if I don't use it to stop the snoring.

I couldn't get comfortable with a mask, but a headset with nasal pillows works perfectly for me.

I'd avoid surgery. My cousin had it and says he has trouble with any thing that requires air pressure, such as blowing up a balloon.

CPAPs are very durable. If you're really pinched for money, there are places that sell them used. This is not a recommendation of that particular place. It's just the first one to come up when I Googled.

Good luck. Your doctor is on your side, and insurers always snap to attention for anyone whose first name is Doctor.
posted by KRS at 7:44 AM on May 14, 2013

Keep in mind that in 2014 Obamacare will prohibit denial of coverage due to pre-existing conditions. Not sure why your insurance policy explicity denies sleep apnea as a covered condition, but if it's possible to wait until 2014 that might change.
posted by citygirl at 10:42 AM on May 14, 2013

They're not denying coverage of a pre-existing condition, they're denying coverage of a procedure or equipment that's not covered by the plan. If you've bought car insurance it's similar to buying additional coverage like rental car coverage. This is very common, especially with individual plans and typically applies to bariatric surgery and reproductive health care procedures as well.
posted by playertobenamedlater at 7:09 PM on May 14, 2013