Anthem Blue Cross of California Policy on Diagnosis of Sleep Disorders

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Permalink Reply by Mike on July 11, 2009 at 7:22am

what a terrific post, Victoria. i guess i'm nutty, but i actually find these insurance companies' rationales for what they will and will not cover fascinating. maybe it's the lawyer in me. you know they sort of have the answer they want as to whether they'll cover for something, and then they go about making a very well constructed argument supporting whatever position they want to take. oops -- sorry to geek out there.

I have Anthem Blue Cross of CA too. I have PPO. One of the key things to know is that you don't ask a provider whether they "take" Blue Cross. You ask whether they are "contracted" for your specific type of coverage -- in my case, PPO. the difference can be 90% reimbursement if they are "contracted" verses 50 or 60% if they merely "take" or "accept" Blue Cross.

Tell us a little more about what happened to you -- I didn't follow so well. Did you get turned down because you had poor compliance?

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Permalink Reply by Victoria Castro on July 11, 2009 at 9:34am

At the beginning of my adventures into sleep apnea I was literally fatigued and runned down. I didn't have any energy to do anything. I was sleepy at work and sleepy behind the wheel. This is when I made an appointment with my primary doctor to discuss my condition. She had me do some blood test and ordered up a sleep study. I was contacted in regards to my sleep study. I didn't really think if they took my insurance or not because I was just so damn exhausted to even think about checking. I was more concerned about my health. I found out it was at the sleep lab that is runned by the hospital that I go to in case of emergency.

After my first sleep study and after discussion with the sleep disorder doctor he said that my numbers weren't high enough to have sleep apnea. I was puzzled because I was very exhausted and I did mention to him that the tech told me that I rolled onto my side and that the tech advised me to sleep on my side until I met with my doctor. Here I go again! I rescheduled for a second sleep study. This time the sleep study would be done at the doctor's office. He had rooms set up that look like a bedroom. It didn't really feel like a hospital lab.

After the second test I met with my doctor and he said that my numbers were high enough to be diagnosed with sleep apnea and that he would prescribe a CPAP Machine; this meant that I would make another appointment for night time to see how much pressure that I would need when I'm sleeping at night. A week went by and I received my medical equipment.

A month later I followed up with my doctor; he informed me that I needed to start using my machine more to be compliant with the insurance company. It was the very first month of usuage. I had some adjusting to make; my dog started sleeping in the closet. I was getting use to my machine. In the meantime, I'm still feeling very fatigued during the day at work. The doctor prescribed Provigil 100mg. I was to cut it in half and take one half in the morning and one half at 2pm. It was working ok for a while. Anyhow, after some time had passed I was up too taking 200mg a day and still feeling sleepy in the afternoon. I'm now on nuvigil.

I discovered that the second sleep study (before the cpap fitting and during the cpap fitting) location that I went to was not a provider after looking at my EOBs. As a state employee without an HMO in my area I am able to get reimbursed for medical expenses. My mother was actually the one that pointed it out to me; she was helping me sort out my EOBs. I called the insurance company and filed an appeal on my EOB because I felt that my provider should have set me up with someone who takes my insurance (or as you said Mike to be contracted). I explained to them that I was very exhausted and fatigued and that I wasn't able to focus or think about checking if I was covered or not. I just lacked the energy to do anything.

But today, I'm more alert and more focused. I am feeling better; but I'm also aware that my current medication is a controlled substance regulated by the FDA. It cost me 45 dollars at my drug store.

Mike said:

what a terrific post, Victoria. i guess i'm nutty, but i actually find these insurance companies' rationales for what they will and will not cover fascinating. maybe it's the lawyer in me. you know they sort of have the answer they want as to whether they'll cover for something, and then they go about making a very well constructed argument supporting whatever position they want to take. oops -- sorry to geek out there.

I have Anthem Blue Cross of CA too. I have PPO. One of the key things to know is that you don't ask a provider whether they "take" Blue Cross. You ask whether they are "contracted" for your specific type of coverage -- in my case, PPO. the difference can be 90% reimbursement if they are "contracted" verses 50 or 60% if they merely "take" or "accept" Blue Cross.

Tell us a little more about what happened to you -- I didn't follow so well. Did you get turned down because you had poor compliance?

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Permalink Reply by Mike on July 12, 2009 at 12:17am

Have you ever had your cpap compliance data analyzed? I wonder whether it needs to be modified.

Victoria Castro said:

At the beginning of my adventures into sleep apnea I was literally fatigued and runned down. I didn't have any energy to do anything. I was sleepy at work and sleepy behind the wheel. This is when I made an appointment with my primary doctor to discuss my condition. She had me do some blood test and ordered up a sleep study. I was contacted in regards to my sleep study. I didn't really think if they took my insurance or not because I was just so damn exhausted to even think about checking. I was more concerned about my health. I found out it was at the sleep lab that is runned by the hospital that I go to in case of emergency.

After my first sleep study and after discussion with the sleep disorder doctor he said that my numbers weren't high enough to have sleep apnea. I was puzzled because I was very exhausted and I did mention to him that the tech told me that I rolled onto my side and that the tech advised me to sleep on my side until I met with my doctor. Here I go again! I rescheduled for a second sleep study. This time the sleep study would be done at the doctor's office. He had rooms set up that look like a bedroom. It didn't really feel like a hospital lab.

After the second test I met with my doctor and he said that my numbers were high enough to be diagnosed with sleep apnea and that he would prescribe a CPAP Machine; this meant that I would make another appointment for night time to see how much pressure that I would need when I'm sleeping at night. A week went by and I received my medical equipment.

A month later I followed up with my doctor; he informed me that I needed to start using my machine more to be compliant with the insurance company. It was the very first month of usuage. I had some adjusting to make; my dog started sleeping in the closet. I was getting use to my machine. In the meantime, I'm still feeling very fatigued during the day at work. The doctor prescribed Provigil 100mg. I was to cut it in half and take one half in the morning and one half at 2pm. It was working ok for a while. Anyhow, after some time had passed I was up too taking 200mg a day and still feeling sleepy in the afternoon. I'm now on nuvigil.

I discovered that the second sleep study (before the cpap fitting and during the cpap fitting) location that I went to was not a provider after looking at my EOBs. As a state employee without an HMO in my area I am able to get reimbursed for medical expenses. My mother was actually the one that pointed it out to me; she was helping me sort out my EOBs. I called the insurance company and filed an appeal on my EOB because I felt that my provider should have set me up with someone who takes my insurance (or as you said Mike to be contracted). I explained to them that I was very exhausted and fatigued and that I wasn't able to focus or think about checking if I was covered or not. I just lacked the energy to do anything.

But today, I'm more alert and more focused. I am feeling better; but I'm also aware that my current medication is a controlled substance regulated by the FDA. It cost me 45 dollars at my drug store.

Mike said:

what a terrific post, Victoria. i guess i'm nutty, but i actually find these insurance companies' rationales for what they will and will not cover fascinating. maybe it's the lawyer in me. you know they sort of have the answer they want as to whether they'll cover for something, and then they go about making a very well constructed argument supporting whatever position they want to take. oops -- sorry to geek out there.

I have Anthem Blue Cross of CA too. I have PPO. One of the key things to know is that you don't ask a provider whether they "take" Blue Cross. You ask whether they are "contracted" for your specific type of coverage -- in my case, PPO. the difference can be 90% reimbursement if they are "contracted" verses 50 or 60% if they merely "take" or "accept" Blue Cross.

Tell us a little more about what happened to you -- I didn't follow so well. Did you get turned down because you had poor compliance?

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