Will Insurance Cover My Sleep Apnea Treatment?
If you have sleep apnea, will insurance cover your treatment?
Sleep apnea is a disorder in which you briefly stop breathing over and over during sleep. In the most common type, obstructive sleep apnea, your tongue and throat muscles relax and block your airway.1 Most often treatment is covered by insurance if the following are true:2
- A sleep study confirms the diagnosis of sleep apnea
- Your doctor prescribes treatment as medically necessary
The most common treatment is a continuous positive airway pressure (CPAP) device. CPAP blows air through a mask and the pressure helps keep your airway open while you sleep.1
CPAP and Medicare
Medicare normally covers a 3-month trial for CPAP treatment only if your supplier is enrolled in Medicare. To keep the machine after that, you must use your CPAP at least 4 hours each night for at least 21 days out of each 30 days. Additional things to know about Medicare include:2-5
- It pays 80 percent of costs for the machine and related supplies, such as mask, tubing, and filters. You pay the remaining costs yourself or from other medical insurance.
- It pays your supplier to rent a CPAP machine for 13 months. After that, you own the machine.
- It covers a new CPAP machine every 5 years
- It pays to replace supplies according to its detailed schedule
CPAP and private insurance
Private insurance normally covers CPAP machines and supplies. Sometimes it follows the same rules as Medicare. The amount of coverage depends on your policy. Most policies cover a new machine every 3 to 5 years.2,4
The American Academy of Sleep Medicine approves oral devices to treat mild to moderate obstructive sleep apnea. Over 100 oral devices are approved by the Food and Drug Administration (FDA). The devices hold your lower jaw forward to prevent your tongue and throat muscles from collapsing and blocking your airway.6
Your oral device should be made and fitted by a dentist trained in dental sleep medicine. Inexpensive oral devices can be bought without a prescription at the drugstore or online. But they can cause jaw problems or tooth movement or can make your sleep apnea worse.6
Oral devices and Medicare
Medicare covers oral appliance therapy as durable medical equipment (DME). The device must meet certain standards. Additional things to know about Medicare and oral devices include:7
- It covers only if your dentist is enrolled in Medicare as a DME supplier
- It covers a new oral device every 5 years
- It pays most of the cost
Oral devices and private insurance
Private insurance normally covers oral devices. Companies often require pre-authorization before treatment begins. This process allows the insurance company to decide whether the treatment is medically necessary and meets the rules for coverage.7
The FDA approved Inspire in 2014. Inspire is a small device placed under the skin of your neck and chest while you are an outpatient. When you go to bed, you click a remote control button to turn Inspire on. It gently stimulates the nerves that control your tongue. Your tongue moves forward and opens your airway so that you can breathe normally.8,9
Medicare and most major insurance companies cover Inspire if you meet the following criteria:10
- You have moderate to severe obstructive sleep apnea.
- You have tried CPAP treatment and cannot use it.
- You are not very overweight.
- You are at least 18 years old.
Many types of surgery treat obstructive sleep apnea. Surgery to the nose, tongue, throat, or jaw is tailored to the needs of the patient. Insurance commonly covers surgery only if less extreme treatments, such as CPAP and oral devices, have not worked.11
Talk to your insurance company and your doctor or dentist to be sure what will be covered by insurance and what your costs will be. Take the following into account:12
- Insurance copays – how much you pay at the time of service
- Deductibles – how much you have to pay before your insurance begins to pay
- Prices charged by different suppliers
When your treatment is prescribed, ask about lower-cost options and if any assistance programs exist.4
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