For people with Central sleep apnea, central sleep apnea, understanding exactly which treatment options are covered under your insurance policy can be time-consuming. Every insurance plan is different, but this blog is designed to help those of you with Medicare Advantage or Commercial insurance understand the prior authorization process that will determine coverage. The content relates specifically to the remedē System for adults with central sleep apnea.
The remedē System is a clinically proven therapy to treat Central Sleep Apnea (CSA)
The remedē System is a non-mask therapy designed for adult patients with moderate to severe central sleep apnea. CSA is a type of sleep apnea that is less common than obstructive sleep apnea (OSA). CSA is a neurological condition that occurs when the brain does not send the correct signals to the breathing muscle (the diaphragm). remedē is a treatment that improves sleep, enhances well-being, and reduces daytime sleepiness, enabling better overall health.1
There are a few important terms to understand before we get started:
Prior authorization: Prior authorization is a request put forth by your medical team to your insurance company to consider your personal case for coverage eligibility.
Medicare Advantage: Medicare advantage plans are alternative options to Medicare. These plans are offered by private insurance companies that are approved by Medicare and usually cover Medicare Part A (hospital insurance) and Medicare Part B (Medical Insurance), and Medicare drug coverage (Part D).
Commercial Insurance: Commercial insurance is health insurance plans offered by private insurance companies. Employer-provided health insurance is often a commercial insurance plan. Individuals can also buy their own policy if they do not receive insurance from their employers or the government.
Reimbursement: Reimbursement is the process by which private insurers or government agencies pay for a healthcare providers’ services.
Insurance coverage for the remedē® System
Each type of insurance plan will review authorization for the remedē System in a slightly different way. However, many Commercial Insurance and Medicare Advantage plans follow a very similar process. Two other types of plans — Medicare (sometimes called “straight” Medicare) and Veterans Administration benefits — will be covered in a future blog.
Commercial Insurance – Providers review and approve the remedē System on a case-by-case basis through the prior authorization process. Your medical team may work with you, the hospital, and the insurance company to gain approval before your remedē procedure.
Medicare Advantage – These plans operate like commercial plans and prior authorization is recommended.
Medicare – Medicare will evaluate each case for medical necessity to determine coverage for the remede System.
Veterans – The remedē System is available for veterans at select VA and military hospitals across the US.
How do insurance companies determine coverage for the remedē System?
Insurance companies think about covering a therapy in two different ways.
The first is an established coverage policy. This is a statement that defines the criteria, and for which patients the insurance company will pay for the therapy. These policies are often written years after FDA approval. It can be a long, multi-year process for insurers to review clinical literature and establish such policies
DID YOU KNOW…?
If you call your insurance company to ask whether a therapy is covered, they will most likely only consider therapies with an established coverage policy “as covered”. However most will also allow a case by case review for medical necessity. It is important to ask your care team to submit a prior authorization – this will allow the insurance company to determine coverage eligibility for your specific case.
The second (and more short term) way that insurance companies determine coverage eligibility is through prior authorization. A prior authorization is a case review for an individual patient. In this case review, the insurance company determines whether a therapy is medically necessary for a specific individual. This is an effective route for patients to request coverage for a therapy where a coverage policy is not yet established. This is very common for a number of years following FDA approval of a technology. Most insurance companies do not yet have a coverage policy for the remedē System. Fortunately, the prior authorization process can be used.
If you choose to pursue remedē therapy to treat central sleep apnea, your care team will guide you through a 3-step process
Consult a doctor to determine if remedē is right for you
The medical center seeks prior authorization
The remedē implant procedure date is finalized
A doctor will work with you to determine your treatment plan and whether remedē is a beneficial treatment option. You may be required to have a sleep study if you have not had one recently. If your doctor determines that you have predominantly central sleep apnea, you may be referred to a sleep or cardiology specialist or electrophysiologist to assess if you are a candidate for the remedē System.
A prior authorization is a request for your insurance company to consider your personal case. Your medical team will request a review of your case to be considered for coverage eligibility. It is important to share with your doctor how central sleep apnea is impacting your daily life as well as your experience with any previous treatments for CSA. Your doctor will then put all your information together and request a prior authorization for your procedure.
Once the prior authorization is approved, your insurance company will send a letter to your physician. The medical center will then reach out to you to schedule a procedure date.
Understanding insurance policies can sometimes be difficult and confusing, but there is good news:
- Commercial and Medicare Advantage plans have established the prior authorization process to help make sure patients have access to therapies that will benefit them – even if they haven’t yet established an overarching coverage policy!
- Your care team can help guide you through the insurance approval process, especially making the case for medical necessity if they believe remedē is the best treatment option for you.
Good luck and remember to stay in communication with your care team to make sure you are on the right path!