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Vol. 14, Issue 17 – August 24, 2015

Does Medicare cover a CPAP device?

Dear Marci,

My doctor diagnosed me with obstructive sleep apnea (OSA) and said that I need a continuous positive airway pressure (CPAP) device to help me breathe at night. I have Original Medicare and was wondering whether it will cover the CPAP device.

– Martine (Chesapeake, VA)

 

Dear Martine,

Original Medicare will cover an initial three-month trial of your CPAP device if you have been diagnosed with obstructive sleep apnea. At the end of the trial, Medicare will continue to pay for the device if your doctor certifies that you have benefited from the device and used it properly.

Before the three-month trial, your physician and supplier must submit paperwork to Medicare to justify your need for a CPAP device. Although it is their job to know these requirements, familiarizing yourself with them can help to avoid errors and navigate any challenges that arise.

To qualify for coverage of a three-month CPAP trial, Original Medicare requires certain steps:

  1. Your doctor must diagnose you with obstructive sleep apnea based on an examination and subsequent sleep test. This test can be performed in your home or at an approved facility.
  2. Your doctor must certify that you had a face-to-face exam with him/her or another health professional within the six-month period before the CPAP was ordered.
  3. You must use a Medicare-approved supplier who provides you and/or your caregiver with instructions about proper use and care for the CPAP device. Many areas including Chesapeake, Virginia are called competitive bidding regions, which means Medicare will usually only pay for most durable medical equipment (DME) from a select group of suppliers, known as contract suppliers.
  4. Lastly, for continued coverage of your CPAP device following the three-month trial, your provider must re-evaluate you during those initial three months. He or she must certify that the CPAP device is helping you and that you are using it as recommended.

If these conditions are met, Medicare will cover 80 percent of the rental fees for a CPAP device for 13 months, once the Part B deductible is met. After that you will own the device. Note that these 13 months include the three-month trial. Medicare will also pay 80 percent of the cost of CPAP supplies, such as masks and tubing.

On the other hand, if your symptoms did not improve during the initial three-month trial of CPAP therapy, you can re-qualify for Medicare coverage following a new sleep study in a facility, and a re-examination by your physician.

Good luck with this process! Remember, you can always talk with your doctor to stay informed about your health care services.

– Marci

 

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Need to Know
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