Medicare Coverage for CPAP & Supplies

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:

  1. A face-to-face clinical evaluation by the treating physician prior to a sleep test assessing the patient for OSA
  2. 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:
    1. Treating physician documents that the patient is benefiting from therapy; and
    2. 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:

  1. CPAP is tried and proven ineffective based on therpeutic trial conducted in either a facility (sleep center) or home setting.
  2. 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:
    1. Mask fit and comfort (read more about different types of mask and how they fit here)
    2. CPAP pressure setting prevent tolerating therapy and lower settings were tried, but failed to:
      1. Control symptoms of OSA; or
      2. Improve sleep; or
      3. 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:

History

  • 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)

Exam

  • 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?

  1. Beneficiary/patient’s name
  2. Treating physician’s name
  3. Date of order
  4. Detailed description of items (type of device and supplies, pressure setting for machine)
  5. Physician signature and signature date
  6. Physician’s NPI
  7. Length of need
  8. Diagnosis

Our service request form meets the requirements for ordering services for Medicare patients. You can download it here:

Download SRF (Rx)

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).

Supply replacement schedule

 

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. 

See our List of Contracted Insurances

Sources:
https://www.medicare.gov/coverage/sleep-study.html 
http://www.aasmnet.org/codingfaq.aspx#350 
https://med.noridianmedicare.com/web/jeb/education/event-materials/polysomnography-and-sleep-studies-qa 
https://med.noridianmedicare.com/documents/10542/2840524/Polysomnograpy+and+Sleep+Studies+Presentation 
http://oig.hhs.gov/oei/reports/oei-07-12-00250.pdf 

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Comments

  1. Martha Deaner Reply

    I have medicare parts A&B. Does medicare cover the SoClean sanitizing machine for cpap machines?

    • Julia Rodriguez Reply

      Hi Martha. Great question. No, Medicare does not cover the SoClean sanitizing machine.

  2. William Reply

    I have equipment that I own before I went on Medicare. What do I need to do to get supplies for it. I need pollen filters and the sponge filters that fit in front. I also need nasal mask and headgear. I had a bipap M Series machine with humidifier. What are my options.

  3. Julia Rodriguez Reply

    Hi William. You should be able to find a local provider for your supplies who accepts Medicare. If you prefer to pay cash, you can work with an online seller who carries Respironics equipment, like CPAP.com.

  4. Kevin R Wall Reply

    My client has been on a bi-pap device (never put on a c-pap by his doctor. This was prior to receiving Medicare, he now needs to get his machine updated. My question is would he need to go through the studies again to do this?

    • Kevin Young Reply

      He will likely need a new study if its been more then 3-6 months depending on the insurance. Some plans for commercial insurance may allow just a detailed compliance with new office notes. Also note that if Medicare is still in play that BiPAP and CPAP are considered same and similar hcpc codes and will need further documentation to bill and/or obtain new.

  5. Dave Zuccolotto Reply

    I have been getting my supplies from appria for over 10 years there lack of services and follow through is not tolerable anymore. could you recommend a approved supplier for me I live in El Dorado Hills, calif.
    Thank Dave Z

    • Kevin Young Reply

      Contact your insurance for a list of providers in your area.

  6. Thomas Graham Reply

    I have been on c pap for 3 years. How many days a month do I have to use the machine to stay eligible with Medicare. thank you. Tom

    • Kevin Young Reply

      The machine itself Is considered purchased after 13 months, Medicare doesn’t generally check compliance after your first 90 days but the basic numbers your looking for in this situation is 80% of your days and at least 4 hours a night

  7. Rosemarie Reply

    Staying at a hotel for 1 night using my Crap machine under Medicare since March 2017. Can I miss bringing my machine for 1 night.

    • Kevin Young Reply

      yes, 1 night should not hurt your overall compliance needed for Medicare to continue coverage on your machine. They generally want 80% usage on days, and average greater then 4 hours per night.

  8. Darlene Brigham Reply

    Does medicre pay for the Airing-Micro Cpap machine

    • Kevin Young Reply

      Medicare pays a set price, fee schedule, for a CPAP device, the type of CPAP you receive is between you and your provider but the minimal amount of profit between the providers cost and what they actually get reimbursed generally doesn’t allow them to provide more than the basic model needed. Sometimes you can negotiate with the provider to pay the difference.

  9. Lynn Reply

    I’m am out of town during the compliance period. Can I go to a clinic or doctor where I am with the SD card ?

    • Kevin Young Reply

      Yes, if you can find a provider that can do the download they will generally help out cause sometimes they convert it to a sale, you may need sanitary wipes or something. The provider, as long as they are accredited, are sworn to be HIPPA compliant so no worries about your medical info being breached.

  10. Susan Donalds Reply

    Why does Medicare NOT pay for a Cpap cleaning machine, such as, SO CLEAN, or VIRTUCLEAN ?

    • Kevin Young Reply

      Because it is not considered a ‘Medical Necessity’

  11. MARY MUNSON Reply

    I have Medicare A & B and AARP Plan F
    Will this cover the SoClean sanitizing machine for cpap machines?

    • Kevin Young Reply

      No, it will not. The SoClean is not considered a Medical Necessity.

  12. Becky Brann Reply

    My cpap machine is getting old, doesn’t work very well. Mask is old. I need a new one, plus the mask,hose,ect. Will Medicare an my supplement ins. Thank you.

    • Kevin Young Reply

      Medicare will cover a new machine every 5 years, sooner in some special cases such as irreparable damage but you must be compliant in this situation, supplies are eligible to be replaced quite frequently look to the table above for how often your new supplies are covered.

  13. Becky Brann Reply

    Machine is old not working very well. Will Medicare an my supplement pay for this?

  14. Robert DeMonte Reply

    Kevin you stated that Medicare will cover a new cpap machine every 5 years
    That is only 80% plus part B deductible if not met
    Correct?

  15. Sue Reply

    I am on APAP, 45 days so far. I am leaving home for 6 months and will not have services for monitoring compliancy for Medicare. Can my DR discontinue therapy, have me return equipment and NOT be charged by Medicare? Thanks

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