Are you enrolled in Medicare or have patients who are?
We reviewed Medicare coverage for sleep studies here.
In this post, learn about Medicare Part B coverage for CPAP and other PAP therapy (Part B covers certain doctor’s services, out patient care, medical supplies and preventative services).
Does Medicare cover CPAP and other PAP therapy for sleep apnea?
Yes. Medicare covers a 3-month trial of for CPAP therapy (learn more about CPAP here) if you’ve been diagnosed wtih obstructive sleep apnea (learn more about OSA here) and meet one of the following criteria:
- AHI or RDI > 15 events per hour with a minimum of 30 events or
- AHI or RDI > 5 to14 events per hour with a minimum of 10 events recorded and documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders or insomnia; or
- Hypertension, ischemic heart disease or history of stroke
Here’s a link to learn more about AHI and RDI, how they’re calculated and what they mean.
Medicare also requires both:
- A face-to-face clinical evaluation by the treating physician prior to a sleep test assessing the patient for OSA
- That the patient or their caregiver received instruction from the CPAP supplier in the proper use and care of CPAP
If you are successful with the 3-month trial of PAP, Medicare may continue coverage if the following criteria are met:
- Clinical re-evaluation between the 31st and 91st day after starting therapy, to include:
- Treating physician documents that the patient is benefiting from therapy; and
- Objective evidence of usage is reviewed by the treating physician
The CPAP supplies (the DME or HME company) can provide the objective data either though a direct data download (learn more about smart CPAP machines here) or through a visual inspection of the usage data documentation provided in a written report that is reviewed by the physician and included in the patient’s medical record. Many other insurance companies are now following Medicare’s lead and requiring proof of usage before continuing to pay for the machine. Learn more about that here.
If adherence to therapy is not documented within the first three months, the patient fails the trial period. If the patient wants to resume therapy, s/he must start the process over with a new face-to-face evaluation and in-center sleep study (home sleep testing is not sufficient).
How does Medicare define CPAP compliance or adherence?
Medicare defines adherence as using the device more than 4 hours per night for 70% of nights (that’s 21 nights) during a consecutive 30 day period any time in the first three months of initial usage.
What is the rental term for PAP therapy?
If the 3-month trial is successful (see above) Medicare will continue to cover the PAP device on a rental basis for up to 13 months in total up to the purchase price of the device (learn about the difference between CPAP rental and purchase here).
Will Medicare cover CPAP if I had a machine before I got Medicare?
Yes, Medicare may cover rental or a replacement CPAP machine and/or CPAP supplies if you meet certain requirements.
When does Medicare cover bi-level or BiPAP?
Medicare will cover a bi-level respiratory assist device without backup (this is what they call a bi-level or BiPAP) for patients with obstructive sleep apnea if the patient meets the criteria for PAP therapy (outlined above) and:
- CPAP is tried and proven ineffective based on therpeutic trial conducted in either a facility (sleep center) or home setting.
- A face-to-face clinical re-evaluation is completed during the 3-month trial period. The physician must document that the following issues were addressed prior to changing from CPAP:
- Mask fit and comfort (read more about different types of mask and how they fit here)
- CPAP pressure setting prevent tolerating therapy and lower settings were tried, but failed to:
- Control symptoms of OSA; or
- Improve sleep; or
- Reduce AHI/RDI to acceptable levels
If the patient switches to a bi-level device within the 3-month trial, the length of the trial is not changed as long as there are at least 30 days remaining. If less than 30 days remain of the trial period, re-evaluation must occur before the 120th day (following the same criteria as CPAP adherence).
What is required in the initial face-to-face clinical evaluation?
Written entries of the evaluation may include:
- Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches
- Duration of symptom
- Validated sleep hygiene inventory such as the Epworth Sleepiness Scale (you can download the scale here)
- Focused cardiopulmonary and upper airway system evaluation
- Neck circumference (this is a risk factor for OSA, learn more here)
- Body mass index (BMI)
What information does Medicare require on the prescription for CPAP and supplies?
- Beneficiary/patient’s name
- Treating physician’s name
- Date of order
- Detailed description of items (type of device and supplies, pressure setting for machine)
- Physician signature and signature date
- Physician’s NPI
- Length of need
Our service request form meets the requirements for ordering services for Medicare patients. You can download it here:
How often does Medicare cover replacement PAP supplies?
Here’s an outline of the Medicare supply replacement schedule. For more detail (including how to tell when your equipment needs to be replaced, check out this post).
How much will Medicare pay for a CPAP or other PAP machine?
Medicare will pay 80% of the Medicare-approved amount for a PAP device after you’ve met your Part B deductible (learn about this and other insurance terms here). If you have a secondary insurance, they may pick up the remaining 20% (read our post about how much sleep studies cost here).
While Advanced Sleep Medicine Services, Inc. is not contracted to bill CPAP machines and supplies for Medicare patients (we do bill for sleep studies), we are contracted with many managed care groups or HMOs that manage Medicare beneficiaries. To see a full list of our contracted insurances, click the button below.
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