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Does Medicare Cover Sleep Apnea


Sleep apnea is a common condition with which many people struggle. Medicare Part B provides coverage for sleep apnea including doctor visits, sleep studies, and equipment to treat the disorder. Depending on the Medicare plan you have, you may be responsible for a portion of the cost.

Does Medicare Cover CPAP Machines?

CPAP Replacement Schedule

The most common type of sleep apnea is obstructive sleep apnea. This is when the soft tissue at the back of the throat collapses during sleep.

Smoking cessation and other lifestyle changes can sometimes keep sleep apnea at bay. However, if your condition is moderate to severe, it may require further treatment.

Most often, sleep apnea is treated with the use of continuous positive airway pressure, or CPAP, machines. Patients use these machines with breathing masks during sleep.

Medicare partially covers the cost of a CPAP machine as durable medical equipment.

To avoid additional costs, be sure your equipment comes from a supplier accepting Medicare assignment.

Additionally, required supplies for a PAP machine receive coverage through Medicare. The Part B deductible applies for all equipment.

If you have a Medigap plan, it will pick up the remainder of the cost. For those with Medicare Advantage, copays, network restrictions, and deductibles could apply.

Check with your provider before scheduling a sleep study or getting sleep apnea treatment equipment.

Medicare Guidelines for CPAP

  1. There is a three-month trial period for CPAP therapy.
  2. Medicare continues covering your CPAP machine after the first three months if your doctor confirms that CPAP therapy is helping.
  3. Medicare pays the CPAP supplier a rental fee for 13 months if used without interruption. After that, you own the machine.
  4. If you have a CPAP machine from before you enrolled in Medicare, there may be coverage for a replacement machine rental or accessories.

What Other Sleep Apnea Devices Does Medicare Cover?

People who have mild to moderate sleep apnea or cannot tolerate a CPAP machine are good candidates for oral appliances. Like a sports mouth guard, the oral appliance holds the jaw forward in a way that keeps the airway open. Oral appliances are comfortable to wear and are quieter and more portable than CPAP machines.

If a CPAP machine isn’t effective in treating your sleep apnea, it’s possible that a bi-level positive airway pressure, or BiPAP, machine could work for you. BiPAP machines provide more air pressure for inhalation and less for exhalation than a CPAP machine. Medicare will pay for a BiPAP machine if the beneficiary has obstructive sleep apnea and has tried a CPAP machine but hasn’t found relief.

Does Medicare Cover the Sleep Apnea Test?

Medicare can offer coverage for sleep studies. However, before treatment, there are specific requirements the patient must meet. Part B of Medicare can cover a sleep study test if your doctor (not dentist) orders it, it is medically necessary to diagnose a condition such as sleep apnea, and sleep is recorded and staged. Medicare won’t cove a sleep study for chronic insomnia.

Even with coverage, you may be responsible for some of the costs. If you have an Advantage plan, talk to your plan provider about in-network practitioners, coverage, and costs. Those with a Medigap policy may pay little to nothing out-of-pocket when receiving treatment.

How Often Does Medicare Pay for a Sleep Study?

Testing frequency depends significantly on the reasons behind needing a new study. There isn’t a lifetime limit on sleep studies. You may need a new study if you discontinue CPAP therapy or fail during the three-month trial period, which is when testing and trials restart.

FAQs

Does Medicare cover home sleep studies?
Home sleep apnea testing is self-administered and receives coverage through Medicare. Along with a physician’s visit, these convenient tests can facilitate a diagnosis of sleep apnea.
Does Medicare cover SoClean?
No, Medicare won’t cover CPAP cleaner such as SoClean 2. But, if you have an HSA or FSA account, you can use the funds to cover CPAP cleaning supplies. Otherwise, payment is your responsibility.
Does Medicare cover the sleep apnea mouthpiece?
Yes, Medicare covers oral appliances for obstructive sleep apnea when you meet specific criteria. To receive reimbursement, a provider must be a DME Medicare Supplier. Meeting Medicare standards and guidelines for coverage is a requirement; if the claim receives a denial, you can always file an appeal.
What sleep apnea pumps will Medicare pay for?
Medicare will cover an implantable pump refill when a physician orders, or personally furnishes a pump.
Does Medicare cover sleep apnea surgery?
Medicare covers essential surgical procedures. When you meet specific criteria, Medicare should cover the surgery. If Medicare covers uvulopalatopharyngoplasty (UPPP), a Medigap plan covers the balance of the surgery. Those with an Advantage plan need to contact their insurer about coverage. Medicare considers Laser-Assisted Uvuloplatoplasty (LAUP) ineffective, and thus, does not provide coverage.

How to Get Help with Medicare Coverage for Sleep Apnea

If you are looking for the best coverage for your sleep apnea needs, we can help! A Medigap plan can cover the holes Original Medicare leaves open and ultimately save you money.

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Lindsay Engle

Lindsay Engle is the Medicare expert for MedicareFAQ. She has been working in the Medicare industry since 2017. She is featured in many publications as well as writes regularly for other expert columns regarding Medicare. You can also find her over on our Medicare Channel on YouTube as well as contributing to our Medicare Community on Facebook.

4 thoughts on “Does Medicare Cover Sleep Apnea

  1. So, I need to use the CPAP machine for 13 months in order for Medicare to pay for it? I have an appointment with my doctor this week but it’s only been 11 months since I started using it. Should I wait 2 more months for the appointment? Although it is working well, I want to discuss another sleep study and alternative treatments, but want to ensure the CPAP is fully paid for before I look into alternatives.

    1. Hi Laurie! Medicare will pay for your CPAP when you first purchase it. After three months, if your doctor verifies that the therapy is helping, your doctor will continue paying for it. It’s not that Medicare won’t cover it until you’ve had it 13 months. Medicare pays a rental fee for the CPAP machine each month, once Medicare has paid that fee for 13 months, the machine becomes yours. Remember, Medicare only covers 80% of the cost. You’ll be responsible for the 20% coinsurance unless you have a Medigap plan. If you’ve had your CPAP machine prior to enrolling in Medicare, you may be eligible for a replacement machine that Medicare will cover at 80%. I hope this helps!

    1. Hi Bobby! This is something newer. Your doctor should know if Medicare will cover it. If not, I would call Medicare directly. In theory, if your doctor finds it medically necessary, just like a CPAP, Medicare should cover it. I reached out to the Inspire media team to see if they could help me answer your question. If they respond, I will update this comment.

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