Medicare Coverage for Sleep Apnea

Understanding Sleep Apnea and Medicare coverage for sleep apnea makes managing the condition easier. If you have been diagnosed with this condition, you could be entitled to coverage on a continuous positive airway pressure (CPAP) machine.

Sleep Apnea is becoming a common issue; about 18 million people living in America are suffering from this disorder. Those with Sleep Apnea experience pauses in breathing during sleep.

There are two types of Sleep Apnea; Obstructive sleep apnea (OSA) and Central Sleep Apnea (CSA). Obstructive Sleep Apnea occurs because the upper airway experiences obstruction during sleep. CSA is less common, it occurs when the brain isn’t sending proper signals to your breathing muscles.

Medicare Coverage of Sleep Apnea Treatments

When you’re diagnosed with Obstructive Sleep Apnea, there is a three-month trial of CPAP therapy that is covered under your Medicare Part B benefits.

Medicare Part B is what covers your DME (Durable Medical Equipment) along with the services and supplies that are needed to effectively use the equipment .

Medicare will cover the initial cost of your CPAP machine for up to 12 weeks, if the OSA diagnosis is being documented by a sleep study.

Medicare will also cover the CPAP machine following the initial 12-week period, but only for the beneficiaries who were diagnosed with obstructive sleep apnea who benefited from the original 12-week period.

If Medicare pays the supplier to rent the equipment, and you have been using the equipment uninterrupted for 13 months then you will own the machine after those 13 months.

Medicare covers these treatments if your health care provider proves that it is medically necessary and that the treatments are improving your condition. In this instance, Medicare Part B will cover 80% and you will pay the remaining 20% of the charges.

Remember, Medicare will pay for a replacement CPAP machine only if it is lost, stolen or damage has been done because of a specific incident.

Medicare will also cover a replacement CPAP machine if the machine is 5 years old or older and is no longer functioning.

Sleep Apnea Explained

Sleep apnea happens when your breathing stops or becomes very shallow while you’re sleeping. During these pauses, your breathing can stop for a few seconds but can even last for minutes at a time.

You could have Sleep Apnea if you experience the following:

• Daytime fatigue
• Morning Headaches
• Memory and concentration issues
• Metabolic syndrome
• Alzheimer’s and Parkinson diseases
• Dementia
• irregular heartbeats (arrhythmias)
• work-related accidents
• driving accidents

Pauses in your breathing can happen up to 30 times or more each hour while you’re sleeping, causing poor sleep quality.

Obstructive Sleep Apnea is the most common form of sleep apnea. Patients with this disorder will have physical blockages or pauses in the airway during their sleep.

Typically, the back of the tongue collapses against the soft palate and then the soft palate collapses against the back of the throat, thus causing the blockage of the airway.

The Dangers of Untreated Sleep Apnea

Sleep Apnea, left untreated, can cause some serious issues. If you think you’re experiencing signs associated with Sleep Apnea, you need to consult your doctor as soon as possible.

If sleep apnea is left untreated it may increase the risk for:

• high blood pressure
• heart attacks
• stroke
• heart failure
• becoming obese
• developing diabetes
• heart failure (or make the condition worse)

Each Medicare beneficiary is eligible for an annual wellness visit, this is considered a preventive service covered fully by Medicare.

What is a CPAP?

CPAP is a machine that is commonly used to administer positive airway pressure. This is the most commonly used method for treating obstructive sleep apnea.  

A CPAP machine operates by blowing gently pressurized air through a tube attached to a mask that the patient wears. This air flow keeps the patient’s throat open, also it acts as somewhat of a splint while the patient is sleeping.

Usually the usage of the CPAP machine is intended for continuous and indefinite use until another form (e.g., loss of weight) will help address the OSA. Weight gain or being overweight is commonly linked to patients with OSA.

Medicare Coverage for Sleep Studies

A health care provider or physician will recommend a sleep study test to determine symptoms of obstructive sleep apnea.

When this happens, beneficiaries are covered 80% by Part B with the remaining 20% of the cost carried by the patient.

Sleep studies are important to determine the type of sleep apnea occurring. It is important to follow through with these studies to get the best possible care for helping your condition.

About the author: Jagger Esch is the President & CEO of Elite Insurance Partners and MedicareFAQ, a senior healthcare learning resource center.