Health Insurance Coverage for Sleep Studies and PAP Therapy FAQ | Advanced Sleep Medicine Services, Inc.

How does my insurance work?

Insurance policies have three main components:

Copay: The amount that you are responsible for paying yourself, as mandated by your insurance contract, to have a sleep study or other services.
Deductible: This is the total amount that the patient needs to pay initially out of pocket before the insurance company makes any payments for medical services. For instance, if your insurance plan has a $1000 deductible per year, you have to pay this amount in full before your insurance company starts to contribute.
Co-insurance: Some insurances have a co-insurance instead of/in addition to a deductible. This means that the patient is responsible for a percentage of the fees of the medical services. For instance, if your insurance plan has a 20% co-insurance, this means that your insurance will make you responsible for 20% of the fees and they will pay the rest. This is usually after the deductible has been met.
Out-of-pocket Maximum: The most you'll have to pay during a policy period (usually a year) for services. Once you've reached your out-of-pocket max, your plan begins to pay 100% of the allowed amount for covered services.

Download the Guide to Understanding Your Health Insurance:

Will my insurance cover my sleep study or PAP device?

Most insurances (HMO, PPO and Medicare) cover sleep studies and PAP therapy for the treatment of sleep disorders. Plans may vary in their coverage (see below: rental versus purchase for PAP device set-ups and in-center denied for in-home sleep testing) and many now require authorization for these services.

It is important to understand your benefits. As a courtesy, we will verify your insurance benefits and request authorization, as needed.

We understand that patients and their physicians are concerned about rising out-of-pocket expenses for health care; unfortunately, this often affects decisions about how healthcare is administered. By contracting as an in-network provider with more payer organizations, more patients can afford to receive the proper diagnosis and treatment for their sleep disorders.

We are contracted with all major PPO plans, Medicare and many HMO plans in California.

Will my insurance company require authorization for my sleep study or PAP device?

Many insurance companies, including PPO and commerical plans, are now requiring authorizations for more and more services, including sleep studies and PAP devices. As a courtesy, we will request authorization from your insurance company, if needed. Sometimes authorizations are denied or more information is required from the patient or physician. If this is the case, we will contact you.

Why did my insurance company deny my in-center study and approve home sleep testing?

Some insurance companies are now denying requests for in-center sleep studies and approving in-home studies (HST) instead. Typically, they will deny a request for in-center testing if there are no significant medical issues and it is highly likely that the patient has moderate to severe sleep apnea.

Home Sleep Testing (HST) can be used exclusively to diagnose or rule out Obstructive Sleep Apnea (OSA). Because of this, it should only be recommended by a doctor if it is highly likely that the patient has moderate to severe sleep apnea, and if the patient has no other significant medical issues such as pulmonary diseases, neuromuscular disease or congestive heart failure. Home sleep studies cannot performed on children and cannot diagnose other sleep disorders such as restless leg syndrome, periodic limb movement disorder or narcolepsy. These patients should be tested in a sleep center. Source: Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive sleep Apnea in Adult Patients. JCSM Journal of Clinical Sleep Medicine, Vol. 3, No. 7, 2007

Will my insurance pay for the purchase or monthly rental of my PAP device?

Many insurance companies are now paying for PAP devices on an on-going monthly basis. When we receive the referral or prescription from your physician, we will verify your insurance coverage and find out how they will pay. You may call us at (877) 775-3377 Option 4 or ask your technologist at the time of set-up if your insurance will be paying as a rental or purchase. You may also call your insurance company to find out.

Why is compliance required for my PAP device rental?

Many insurance companies now pay for PAP devices on a monthly rental basis, typically 4 to 10 months. At the end of this period you will own the device. Because it is a monthly rental, we will bill your insurance company monthly. If you have a co-insurance, you will also be billed monthly.

Compliance guidelines:

Most insurance compliance guidelines require that you show proof of using your device for a minimum of 4 hours per day at least 22 days out of a consecutive 30 day period within the preceding 90 days (in the past 3 months).

What are the CPT codes used for sleep studies, PAP device set-ups and resupply?

Sleep studies:

Home sleep testing (HST): 95806, G0398 or G0399 depending on the insurance company and type of device used.

In-center polysomnography (PSG): 95810 (95782 for children under 6 years old)

Split night or 50/50 study, PAP titration study: 95811

Multiple Sleep Latency Test (MSLT): 95805

Click here for a comprehensive guide listing common study types, reasons for testing and CPT codes.

PAP device and supplies:

Continuous PAP (CPAP) or auto set PAP (APAP): E0601

Bilevel PAP (BiPAP): E0470

BiLevel with pressure support (ASV): E0471

Heated humidifier: E0562

Waterchamber: A7046

Mask* (nasal or nasal pillows): A7034 Full-face mask: A7030 Headgear: A7035 Chinstrap: A7036

Nasal mask cushion: A7032 Nasal pillows cushion: A7031 Full-face mask interface: A7033

Disposable filters: A7038

Tubing: A7037 Heated tubing: A4604

*Attention Patients with Medicare: Due to Medicare regulations, which must be followed by your insurance, your mask kit will be billed using two separate codes. According to your mask type you will find the following combination of codes on your order invoice: either (A7030 & A7035) or (A7034 & A7035). Codes A7034 and A7030 refer to the frame of your mask, while A7035 refers to the headgear. Although they are billed separately they come assembled in the same bag. Please contact your insurance with any questions and reference the codes.

How often will my insurance pay for replacement PAP supplies?

Many insurance plans follow the guidelines from Medicare for regular replacement of supplies. You can review the guidelines online at http://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf. Medicare guidelines suggest replacing your supplies at the following frequency*:

*Your particular insurance plan may have a different allowance for replacement supplies. This is why we will verify your coverage to determine your allowance before processing your order. You may purchase additional replacement supplies at our cash prices if you would like more supplies than your plan allows.

Insurance Coverage for Sleep Studies and PAP Therapy

Frequently asked questions (FAQs).

FAQs

How does my insurance work?

Download the Guide to Understanding Your Health Insurance:

Will my insurance cover my sleep study or PAP device?

Will I have a copay?

Will my insurance company require authorization for my sleep study or PAP device?

Why did my insurance company deny my in-center study and approve home sleep testing?

Will my insurance pay for the purchase or monthly rental of my PAP device?

Why is compliance required for my PAP device rental?

Compliance guidelines:

Why is compliance required for my regular replacement supplies?

What are the CPT codes used for sleep studies, PAP device set-ups and resupply?

Sleep studies:

PAP device and supplies:

How often will my insurance pay for replacement PAP supplies?

Who can I contact if I have other questions?

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