The patient clearly has sleep apnea, but it’s not severe enough for the insurance company to cover therapy. Why?
Unfortunately, there are varying opinions about how sleep apnea is diagnosed and when CPAP is the appropriate therapy.
Primarily, the difference is between how Medicare (CMS) and the American Academy of Sleep Medicine (AASM) define a diagnosis of sleep apnea. And many commercial insurances are starting to follow Medicare’s guidelines for CPAP coverage.
In this post we’ll explain what insurance companies, including Medicare, are looking for in a sleep study to determine coverage for CPAP. We’ll offer suggestions of what to do if insurance won’t cover CPAP.
What’s the difference between AHI and RDI?
AHI stands for Apnea Hypopnea Index. It’s the average number of combined apneas and hypopneas per hour. It is most often used to determine the severity of a person’s sleep apnea. An apnea is when your breathing stops for at least ten seconds while sleeping (learn more about the basics of sleep apnea here). A hypopnea is a significant reduction in airflow while sleeping (not a complete stop) that causes a drop in blood oxygen saturation and then an arousal.
RDI stands for Respiratory Disturbance Index. This is your combined number of apneas, hypopneas, and RERAs per hour of sleep. RERA stands for respiratory effort related arousal is an event that causes an arousal or a decrease in oxygen saturation, without qualifying as an apnea or hypopnea.
AHI has been the traditional measure used to determine the severity of sleep apnea; however, some institutions and insurances are looking at RERAs because any respiratory event that lasts at least 10 seconds and causes an arousal can cause damage and should be treated. The chart below lists AHI criteria.
Is your sleep apnea normal, mild, moderate or severe?
None/Normal: Almost everyone experiences the occaisional apnea event while sleeping, so having less than 5 of these events per hour is considered normal and no treatment is recommended.
Mild Sleep Apnea: CPAP is not always recommended as the first option for treating mild sleep apnea. Other interventions, such as weight loss, use of positional tricks (if sleep apnea occurs primarily while sleeping supine, or on your back), improvements in sleep hygiene and oral appliances may be recommended (learn more about CPAP alternatives here). This is the fuzzy area for CPAP coverage.
Moderate and Severe Sleep Apnea: CPAP therapy is usually recommended. Most insurance companies will authorize payment for CPAP if your AHI is moderate to severe (learn about how CPAP therapy works to treat sleep apnea here).
Medicare vs. AASM guidelines
Medicare defines RDI as the average number of apneas and hypopneas (so it’s really the same as AHI), they do not include RERAs. In order for Medicare to coverage CPAP for sleep apnea, the patient must meet one of the following criteria for obstructive sleep apnea to be diagnosed:
- AHI or RDI must at least 15 events per hour (read more about the other Medicare requirements for CPAP coverage here).
- AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness (EDS); impaired cognition; mood disorders; insomnia; or documented hypertension, ischemic heart disease, or history of stroke.
Some insurances refer to the American Academy of Sleep Medicine (AASM) standards for RDI which includes apneas, hypopneas or RERAs.
When we, at Advanced Sleep Medicine Services, score sleep studies, we include RERAs in our calculation for RDI.
The AASM requires one of the following criteria be met for a diagnosis of sleep apnea:
- The patient reports daytime sleepiness, unrefreshing sleep, fatigue, insomnia, and/or unintentional sleep episodes during wakefulness. The patient awakens with breath holding, gasping, or choking. The patient’s bed partner reports loud snoring, breathing interruptions, or both during the patient’s sleep.
- Polysomnography (PSG) shows more than 5 scoreable respiratory events (eg, apneas, hypopneas, RERAs) per hour of sleep and/or evidence of respiratory effort during all or a portion of each respiratory event.
- PSG shows more than 15 scorable respiratory events (eg, apneas, hypopneas, RERAs) per hour of sleep and/or evidence of respiratory effort during all or a portion of each respiratory event.
- Another current sleep disorder, medical or neurologic disorder, medication use, or substance use does not better account for the patient’s condition.
If a patient has an RDI greater than 15 (including RERAs) but their AHI (called RDI by Medicare) is under 15, Medicare and other insurances will not approve CPAP therapy for a diagnosis of sleep apnea.
Our experience in California is that some Blue Cross policies (primarily those who use AIM to manage utilization), some Blue Cross Blue Shield policies and Aetna will consider RDI when determining coverage. All other commercial plans are following Medicare guidelines.’
There is no universal standard about whether AHI or RDI should be used for diagnosis and Medicare varies by region as to whether AHI and RDI can be used. One study found that 30% of symptomatic patients would have been left untreated if the AHI were used rather the RDI.
What should I do if my insurance won’t cover CPAP?
If you and your doctor determine that CPAP is the best course of treatment, but your insurance will not cover CPAP because you do not meet the Medicare requirements, you have a couple of options:
- Contact your insurance company. If you do not meet Medicare requirements but meet AASM guidelines, tell them so! Unfortunately, Medicare won’t budge unless you have documented symptoms of excessive daytime sleepiness or the other medical conditions listed above.
- Ask your doctor to contact your insurance company. Your doctor’s office can review your chart to see if you have other documented symptoms that may help get approval. A call from your physician can go a long way, but it takes a lot of time and effort on their part.
- Pay cash for a CPAP.
- Look online for an organization that provides free or low-cost CPAPs (we have a list here).
- Consider having another sleep study. Your sleep apnea may not have been recorded at its worst on the night of your sleep study. For example, many patients have more severe sleep apnea while in REM sleep or when sleeping on their backs. Your second study may not be covered by your insurance (read more about how much a sleep study costs here).
If you have sleep apnea and would like to use CPAP therapy but are unsure of whether your insurance will pay, contact us to verify your benefits and discuss alternatives.
Other posts you may find interesting:
Virginia FuchsPosted on July 09, 2018
CPAP Model # J15649766679B
Have used 2+ years.
AHI in high teens – low 20’s
3 sleep studies AHI 1-2
Lung function test is normal
Oximeter readings normal (96% – 99%)
Why is my CPAP showing high AHIs and all others low.
Sleep studies use different CPAPs.
Please help me know what to do!
Donald BedfordPosted on March 15, 2019
I was diagnosed 2009 with mild sleep apnea, was given a cpap, tricare paid for. Last year i tried to get a updated machine with bluetooth. Had another sleep study but this time they said i did not need a machine. Over the course of a year i was tired all the time. Had morning headaches, bone pain, angry all the time. Memory loss. Went back to my doctor, got another sleep study, same results only at the bottom, said if other recommendations dont work, suggest cpap therapy. Got a new prescription for a auto cpap. Medicare wont cover it. I am currently trying to get the VA to cover it since i am 100% VA with sleep apnea being 50% of that. Still waiting and using my 10 year old cpap.
Slope 2 unblockedPosted on January 09, 2022
I was diagnosed with minor sleep apnea in 2009 and was prescribed a cpap machine, which was paid for by tricare. Last year, I attempted to obtain a bluetooth-enabled machine. I had another sleep study, but this time they determined that I did not require the use of a machine.
Kris CranePosted on March 02, 2022
An apnea is when your breathing stops for at least ten seconds while sleeping…
Ayushi BasuPosted on May 04, 2022
By publishing an article with important information you have provided very important facts to our readers and visit others we will share it with our other partner
Andheri Call GirlPosted on May 04, 2022
You keep publishing such good speculations I will share them with my friends
Article SubmissionPosted on May 04, 2022
We invite you to publish a good article on your blog where you can publish great information and help in search engine optimization
Demat AccountPosted on May 04, 2022
Open a Free Demat account for stock market investing and daily trading. We provide you with 24/7 support with guidelines.
dordlePosted on July 10, 2022
When you publish an article containing vital details for our readers, we will make sure to pass it along to our other partners.
Mumbai One BeautiesPosted on August 05, 2022
A great job was done with your valuable information I will definitely share it with my friends
ManshiPosted on August 05, 2022
You wrote the article with good information, I agree with you if you visit Mumbai then you should do something to entertain yourself.
run 3Posted on August 23, 2022
Thank you very much for these great cake recipes, I have learned a lot from your web blog
kame paradise 3Posted on August 26, 2022
A great job was done with your valuable information I will definitely share it with my friends.
Minecraft storage roomPosted on September 09, 2022
What a catchy piece of art have you included in your article? I appreciate the pictures because they seem so appealing and authentic. fantastic originality I also run a fun website where you can learn about games. Hopefully, this will enable you to improve your gaming abilities and proceed to a higher level.
start reading about Minecraft. thus, you will receive Minecraft storage room design settings.
drift bossPosted on September 30, 2022
Thank you for answering this issue. It is really necessary. Family members of nahan disease need to know this. Because if not, there will be misconceptions that are not worth it. Thanks so much for sharing!
Right Clck CounterPosted on November 20, 2022
Thank you for providing updates on the medical services. As you are aware, new technologies are always being developed. I also have a right click counter exam that you can do online to get feedback on how well you manage your computer’s mouse.
wordlePosted on December 03, 2022
The content is good and useful. I love this article.
fnaf security breachPosted on January 31, 2023
Thanks for all the other information you share. Where can I get this kind of information written in such an ideal medium. I will keep an eye on such information.
LorainPosted on May 22, 2023
Our expert technicians leverage state-of-the-art diagnostic tools to swiftly pinpoint the root causes of any issues and formulate a dependable repair plan.