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Your sleep apnea claim was denied. Here’s how to appeal it.

Two things worth knowing before anything else.

You have a deadline, and it’s running. Under federal rules covering ACA-compliant and most employer plans, you generally have 180 days from the denial notice to file an internal appeal. Miss it and you can lose the right entirely.

Very few people appeal. Denials frequently come down to a missing document, a coding error, or a prior-authorization technicality rather than a judgement about your care — and those are exactly the kind an appeal fixes.

Step one: find the actual reason

Do not appeal until you know precisely what you’re appealing. The denial letter states a reason, sometimes in language designed to sound final. It usually falls into one of these.

“Not medically necessary.” The insurer says the documentation doesn’t establish that you need this. In sleep apnea this most often means your sleep study results, symptoms, or diagnosis codes weren’t submitted in the form the policy requires — not that anyone reviewed your case and disagreed.

“Prior authorization not obtained.” Approval was required before the service and wasn’t secured. Frustrating, frequently appealable, and often the practice’s error rather than yours.

“Not a covered benefit.” The plan says it doesn’t cover this category at all. The hardest to overturn — but check whether the service was submitted under the wrong benefit. An oral appliance denied by a dental plan may simply have gone to the wrong place.

“Documentation insufficient.” Something specific is missing. This is the most winnable denial there is, because the fix is supplying the thing.

Compliance-based denial. Specific to PAP therapy: coverage stopped because documented usage didn’t meet the threshold. This one has its own path — see below.

Get the policy the denial was based on. You’re entitled to the plan documents and the specific criteria applied. Ask for them in writing. Appealing without knowing the criteria means guessing at what to rebut.

Step two: the internal appeal

Filed with the insurer. Someone other than the original decision-maker must review it.

Deadline: generally 180 days from the denial notice. Your letter states the exact date — that date wins over any general rule.

Their deadline: typically 30 days for services you haven’t received yet, 60 days for claims already incurred, and about 72 hours for urgent situations.

What to include:

• Your name, member ID, claim number, and the date of denial
• The denial reason quoted exactly as the insurer worded it, so it’s unambiguous what you’re rebutting
• A point-by-point response, each pointing at a document that answers it
• A letter of medical necessity from your treating clinician
• The supporting records: sleep study report with the AHI or RDI documented, chart notes, the prescription or order
• The plan’s own criteria, if you obtained them, with the parts you meet identified

Keep it calm and specific. This is a documentation exercise, not a persuasive essay.

Ask your clinician about a peer-to-peer review. Many insurers allow the prescribing clinician to speak directly with their medical director. It’s often faster than a written appeal and sometimes resolves the whole thing.

Step three: external review

If the internal appeal fails, an independent third party reviews the case fresh. Their decision binds the insurer — if they side with you, it gets paid.

Deadline: generally 4 months from the final internal denial.

Their deadline: no later than 45 days for a standard review, and as little as 72 hours for an expedited one.

Cost: typically nothing or a nominal fee, depending on your state.

Contact details for the body handling your external review appear on your final internal denial or your explanation of benefits. In urgent situations you can request external review without finishing the internal process.

Success rates vary by state and denial type, but external review overturns a meaningful share of denials — Massachusetts, for example, reports that over 40% of external review decisions go in the patient’s favour. Filing costs you a form and a deadline.

The compliance denial is different

If your PAP coverage stopped because of usage rather than eligibility, appealing the paperwork usually isn’t the answer. The insurer isn’t disputing that you have sleep apnea; it’s saying you didn’t use the machine enough.

Medicare’s standard is at least four hours a night on 70% of nights during a consecutive 30-day period within the first three months — 21 nights out of 30. Most commercial plans mirror it.

This is usually a pause, not a permanent no. The path back is to fix the reason you weren’t using it and re-attempt. And the reason is very often a mask that doesn’t fit, which is a solvable equipment problem rather than a verdict on the therapy.

→ Why your mask leaks, and what to change → Medicare’s compliance rule, explained

Two things people miss

File a complaint with your state insurance commissioner in parallel. It costs nothing, creates a formal record, and sometimes moves things that an appeal alone doesn’t.

Document the failure even if you give up on the treatment. If PAP genuinely isn’t working for you, telling your clinician so — and having it recorded — is what makes an oral appliance or a surgical option coverable later. Many plans require documented PAP intolerance before they’ll pay for an alternative. Simply stopping leaves no record and can make the next thing harder to get.

Deadlines and procedures described here are the general federal standards for ACA-compliant and most employer plans. Some states allow longer, and Medicare Advantage follows a different track. The date on your own denial letter governs — read it the day it arrives. This is not legal advice.