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 when a physician deems it medically necessary.
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Depending on the Medicare plan, you may be responsible for a portion of the cost. We are here to familiarize you with the sleep apnea devices covered by Medicare.
Does Medicare Cover CPAP Machines?
The most common type of sleep apnea is obstructive sleep apnea. When someone has this condition, the soft tissue at the back of their throat collapses during sleep.
Sleep apnea is often treated using continuous positive airway pressure, or CPAP, machines. Patients use these machines with breathing masks during sleep.
Medicare partially covers the cost of a medically necessary CPAP machine as durable medical equipment. To avoid incurring additional costs, Original Medicare (Medicare Part A and Part B) beneficiaries must receive their CPAP machine from a supplier accepting Medicare assignment.
Additionally, required supplies for a CPAP machine receive coverage through Medicare. Keep in mind that the Medicare Part B deductible applies to all equipment.
If you have a Medicare Supplement (Medigap plan), it will cover the remainder of the cost. Medicare Part B will pay for 80% of sleep apnea devices covered by Medicare after you meet the deductible. However, if Medicare approves your device, Medigap will pay for the remaining 20%, and you will receive complete coverage.
Copays, network restrictions, and deductibles could apply for those with Medicare Advantage. Check with your provider before scheduling a sleep study or getting sleep apnea treatment equipment.
Does Medicare Cover Alternative Sleep Apnea Treatment?
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.
Popular alternative treatments to CPAP for sleep apnea include BiPAP, APAP, dental appliances, surgery, weight loss, and positional therapy.
Under certain circumstances, Medicare will cover each of these alternative treatment options. However, Medicare will only cover one treatment option at a time.
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For example, if you receive a CPAP machine through Medicare, they will not cover the positional therapy you receive simultaneously. The reason for this is that both treatment options have the same goal. Covering two treatment types would be redundant for Medicare.
Medicare CPAP Guidelines for 2022
Beneficiaries must meet specific criteria to qualify for Medicare coverage of a CPAP machine.
- Complete a sleep study monitored by a licensed health professional
- Diagnosed with sleep apnea based on sleep study results
- Obtain a CPAP prescription from your doctor
- Purchase a CPAP from a participating Medicare supplier
Because CPAP treatment is not effective in every case, Medicare covers a three-month trial period with a CPAP machine. After three months, your doctor will reevaluate your need for the CPAP machine and if the treatment is working for your condition.
After this review, Medicare will decide to cover CPAP treatments long-term or not to cover the machine based on your doctors’ assessment.
Does Medicare Cover a Sleep Study for Sleep Apnea?
Medicare can offer coverage for sleep studies. However, before treatment, the patient must meet specific criteria.
Medicare Part B can cover a sleep study test if your doctor orders it, if medically necessary to diagnose a condition such as sleep apnea and if sleep is recorded and staged. However, Medicare will not cover a sleep study for chronic insomnia.
Even with coverage, you may be responsible for some of the costs. If you have a Medicare 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.
Does Medicare Pay for Dental Appliances for Sleep Apnea?
Oral appliances for obstructive sleep apnea receive coverage if you meet specific criteria. The mandibular advancement device is the most popular dental appliance to help treat sleep apnea. This retainer-style medical oral appliance is one of the sleep apnea devices covered by Medicare if the situation qualifies. Thus, Medicare will cover the device if it is medically necessary.
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A dental appliance is only covered by Medicare if it is your only form of treatment for sleep apnea. If you receive positive airway pressure (PAP), Medicare will not cover the dental appliance as it is viewed as a convenience item. The same applies to CPAP, BiPAP, and APAP.
PAP treatment is considered superior to dental appliances. So, Medicare tends to cover PAP over dental appliances.
FAQs
How to Get a CPAP Machine Through Medicare
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 save you money. So, if you qualify for a CPAP machine or any of the other sleep apnea devices covered by Medicare, a Medigap plan can provide you with complete coverage!
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Sources:
MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.
- Sleep Apnea, Mayo Clinic . Accessed May 2022.
https://www.mayoclinic.org/diseases-conditions/sleep-apnea/symptoms-causes/syc-20377631 - Sleep Apnea, Sleep Foundation. Accessed May 2022.
https://www.sleepfoundation.org/sleep-apnea - CPAP Coverage, Medicare. Accessed May 2022.
https://www.medicare.gov/coverage/continuous-positive-airway-pressure-devices - Sleep Studies, Medicare. Accessed May 2022.
https://www.medicare.gov/coverage/sleep-studies
Does a person who is under the age of 65 with severe Central Sleep Apnea qualify for assistance?
If you are under 65, you will only receive Medicare if you have been on Social Security Disability benefits for 24 months or more.
Can you advise if any surgical sleep apnea solutions are covered? Do is obstructive sleep apnea but unable to tolerate CPAP
Hi Jackie, there are certain surgical procedures covered by Medicare if you meet specific criteria. Here, you can review the guidelines directly from CMS regarding sleep apnea surgery covered by Medicare.
When initially getting set up on CPAP, does your sleep study need to be within a year of that?
Great question! When initially being prescribed a CPAP, the validity time of the sleep study depends on the type of sleep study being performed. It is best to speak with the doctor who will be prescribing your machine as they would ultimately be the determining factor of when the study needs to be completed.
Hello. 1) How often does Medicare require an appt with my sleep doctor in order to continue to receive CPAP supplies and support?
2) When I use my dental appliance while traveling for 5 weeks overseas, does that affect Medicare’s coverage for my CPAP machine? (I have a 95% rating when using CPAP)
3) Does Medicare cover the cost of the dental appliance?
Thank you very much.
Hi Andrew!
1) It depends on the severity of your condition, your doctor should know the answer to this question.
2) No, this should not affect your CPAP coverage. However, if you need any supplies shipped to you while traveling to another address aside from your home address, you may have an issue.
3) Yes, coverage will fall under Part B.
You’re very welcome!
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.
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!
Does medicare cover the sleep apena “Inspire” solution?
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.