A Continuous Positive Airway Pressure (CPAP) machine is the primary treatment for Obstructive Sleep Apnea (OSA), a condition where breathing repeatedly stops and starts during sleep. The machine delivers pressurized air through a mask, which helps keep the upper airway open. Medicare covers this equipment, treating it as Durable Medical Equipment (DME). Coverage is provided through Medicare Part B, but is managed under a specific set of rules and requirements.
Eligibility and Diagnostic Requirements
To qualify for Medicare coverage of a CPAP device, the process begins with a formal medical diagnosis of Obstructive Sleep Apnea. This diagnosis must be confirmed through a sleep study, known as a polysomnogram, which can be performed in a sleep lab or through an approved home sleep test. The results of this study must demonstrate a severity that warrants CPAP therapy, typically measured by the Apnea-Hypopnea Index (AHI).
A treating physician must then write a prescription for the CPAP machine, affirming its medical necessity. The physician and the Durable Medical Equipment (DME) supplier providing the machine must both be enrolled in and participate with the Medicare program for the costs to be covered. The coverage for the machine and the sleep study itself falls under Medicare Part B.
The Mandatory 13-Month Rental Period
Medicare uses a structured rent-to-own model, beginning with a trial period to assess effectiveness. For a newly diagnosed patient, Medicare covers an initial three-month trial rental of the CPAP machine. If the therapy is successful, the rental continues for an additional ten months, totaling a 13-month duration before the patient owns the machine. Continuation of coverage beyond the trial period is strictly dependent on proving compliance with the therapy. Medicare requires objective data, typically downloaded from the CPAP machine, demonstrating regular usage.
Compliance Requirements
The standard compliance rule dictates that the machine must be used for a minimum of four hours per night for at least 70% of the nights during the initial 90-day trial. The prescribing physician must document in the patient’s medical record that the machine is being used and that the therapy is effective. If the patient fails to meet this minimum compliance requirement, Medicare may discontinue its monthly rental payments for the machine. The patient may be required to return the equipment to the DME supplier or assume the full remaining cost themselves. Once Medicare has made the rental payments for 13 continuous months, the patient takes full ownership of the CPAP device.
Ongoing Costs and Replacement Supplies
While Medicare covers the CPAP machine, patients are responsible for certain out-of-pocket costs, consistent with Part B coverage for Durable Medical Equipment. After meeting the annual Part B deductible, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for the machine’s rental payments. This 20% coinsurance obligation also applies to all necessary replacement supplies, which are covered on a specific schedule. CPAP supplies, such as masks, tubing, and filters, require regular replacement to maintain hygienic and effective therapy.
Replacement Schedule
Medicare has established a replacement schedule for these items, with frequency varying based on the component:
- Disposable filters and cushions may be covered for replacement as frequently as twice a month.
- The full mask may be covered quarterly or semi-annually.
- Tubing and headgear are typically covered for replacement every three to six months.
- The humidifier water chamber is covered semi-annually.
Patients enrolled in a Medicare Advantage Plan (Part C) still receive at least the same coverage as Original Medicare, but their specific out-of-pocket costs may differ based on the plan’s structure.