Denials in sleep medicine fall into two recurring patterns: a plan steering an in-lab polysomnogram to a home sleep apnea test (or denying the in-lab study), and PAP-therapy denials — initial device, titration, or re-supply — that turn on documented adherence. The appeal restores the clinical indication for the test setting, or supplies the adherence and benefit documentation the policy requires.
Why these denials happen
Plans default to home sleep apnea testing for uncomplicated suspected obstructive sleep apnea and require a documented indication for in-lab polysomnography (comorbidities, suspected non-OSA disorders, or a failed/inconclusive home test). PAP coverage is conditioned on a qualifying study and, for continued coverage and re-supply, on adherence data meeting the policy threshold and documented benefit. AASM standards and Medicare LCDs are the reference points; the denial flags the missing indication or the adherence gap.
The common denials
- In-lab polysomnography denied in favor of a home sleep apnea test.
- Home test result deemed insufficient to qualify the diagnosis or PAP.
- PAP device denied — qualifying study or AHI threshold not documented.
- Continued PAP or re-supply denied — adherence data below the policy threshold.
- Procedure or device not matched to the plan's or the LCD's criteria.
Is it worth appealing?
Sometimes worth appealing
How to appeal
- 1
Justify the test setting
For an in-lab study, document the comorbidities, suspected non-OSA disorder, or failed home test that make in-lab polysomnography the indicated test under AASM standards.
- 2
Supply the PAP qualifying criteria
Document the qualifying study and the AHI threshold the policy requires for the device.
- 3
Document adherence and benefit
For continued coverage or re-supply, attach the adherence data meeting the policy threshold and the documented clinical benefit.
Frequently asked
The plan wants a home test, but my doctor ordered an in-lab study.
My PAP re-supply was denied for adherence — can I appeal?
Clinical-coverage patterns and guideline references are summarized for plain-language reference and vary by plan and payer policy. This is general information for clinicians and billing staff, not medical, legal, or coding advice — confirm against the governing coverage policy and the current guideline for each claim.
When the appeal has to be written, and cited
Upload the denied EOB and Merits returns a complete, citation-verified appeal letter — the clinical argument, the payer's own coverage criteria, and your federal appeal rights — in about a minute.