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Medicare Coverage of CPAP Machine

Sleep apnea is a serious condition that happens when a person’s breathing is interrupted while they are sleeping. People with untreated sleep apnea don’t take in enough oxygen causing them to gasp and often wake up during the night.This can sometimes happen up to hundreds of times a night. 

In many cases, people are unaware that they’ve stopped breathing, and believe that their sleep cycle is normal. Sleep apnea can sound a lot like snoring.

What are the symptoms of sleep apnea?

Often the first signs of sleep apnea may not even be recognized by the person suffering the disorder, but by a bed partner. Many of those affected have no sleep complaints at all. The most common signs and symptoms of OSA include:

➤Snoring
➤Daytime sleepiness or fatigue
➤Restlessness during sleep, frequent nighttime awakenings
➤Sudden awakenings with a sensation of gasping or choking
➤Dry mouth or sore throat upon awakening
➤Cognitive impairment, such as trouble concentrating, forgetfulness or irritability
➤Mood disturbances such as anxiety or depression
➤Night sweats
➤Frequent nighttime urination
➤Headaches

There are two types of sleep apnea: Obstructive and Central:

  • Obstructive sleep apnea is the most common of the two types, and is caused by a blockage of the airway, usually when the soft tissue in the back of the throat collapses during sleep. During an episode, the diaphragm and chest muscles work harder as the pressure increases to open the airway. Breathing usually resumes with a loud gasp or body jerk. These episodes can interfere with deep sleep, reduce the flow of oxygen to the vital organs, and cause heart rhythm irregularities.

  • Central Sleep Apnea, Central sleep apnea is usually observed in patients with central nervous system dysfunction, such as following a stroke or in patients with neuromuscular diseases like Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig’s disease). It is also common in patients with heart failure and other forms of heart, kidney or lung disease. People with central sleep apnea more often report recurrent awakenings or insomnia, although they may also experience a choking or gasping sensation upon awakening.

 

If left untreated, sleep apnea can cause a number of health problems including:
High Blood Pressure
✅Stroke
✅Cardiomyopathy (enlargement of the heart muscles)
✅Heart Failure
✅Diabetes and
✅Heart Attacks


Who Is At Risk For Sleep Apnea?

Sleep apnea occurs in about 25% of men and roughly 10% of women. Sleep apnea can affect people of all ages and certain physical traits are common in patients with obstructive sleep apnea. These include:
➤Excessive weight
➤Having a large neck
➤Structural abnormalities that reduce the diameter of the upper airway, such as nasal obstruction, a low-hanging soft palate, enlarged tonsils or a small jaw with an overbite.

Diagnosing Sleep Apnea:

 

Your doctor may make an evaluation based on your signs and symptoms and a sleep history, but it is a likely possibility to be referred to a sleep disorder center. There, a sleep specialist can help you determine your need for further evaluation.

An evaluation can involve being monitored overnight at a sleep center, but home sleep testing also might be another option. Testing in a sleep center can be a more in depth way for a sleep specialist to diagnose sleep apnea. During this kind of testing, also called Nocturnal Polysomnography,you’re hooked up to equipment that monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood oxygen levels while you sleep.

If your doctor decides to put you through a home sleep study, it is less invasive and more simplified. These tests usually measure your heart rate, blood oxygen level, airflow and breathing patterns. If the results are abnormal, your doctor might be able to prescribe a therapy without further testing. However, portable monitoring devices do not detect all cases of sleep apnea so your doctor could still recommend polysomnography even if your initial results come back normal. 

 

Treatment of Sleep Apnea:

Once you have been diagnosed as having sleep apnea, your doctor can suggest several different treatment options to try to combat it such as weight loss, wearing of oral/dental appliances, positional therapy, certain surgeries, and CPAP Therapy. Out of those options, CPAP Therapy is generally the most popular.

What is a CPAP Machine?

This is how a Sleep.org defines a CPAP machine: CPAP stands for continuous positive airway pressure. The machines help people with sleep apnea breathe more easily and regularly every night while they are sleeping. A CPAP machine increases the air pressure in your throat to prevent your airway from collapsing when you inhale. It also decreases snoring. The machine has a filter and small tank of water, which essentially works as a humidifier. There is a tube that connects the unit to a mask that you place over your face while you sleep, and a chin strap keeps it in place.

From Medicare.Gov: If You Are Enrolled In Medicare:

If you are enrolled in Medicare and your doctor makes the recommendation that you use a CPAP machine while you are sleeping, here is what you need to know.

Medicare Part B covers CPAP machines under the durable medical equipment benefit. However, to qualify for the CPAP coverage you must meet the following requirements:

Complete a sleep test in a laboratory setting or by using an approved at-home test
✅Be diagnosed with obstructive sleep apnea based on sleep test results
✅Have a prescription for a CPAP machine from your doctor
✅Get the CPAP machine from a participating Medicare supplier

How Much Does a CPAP Machine Cost With Medicare?

Since CPAP treatment does not work for everyone, Medicare first covers the machine for a 12 week trial period. After the trial period is over, your doctor will check how the treatment is working for you. Medicare may cover CPAP therapy long term if your doctor verifies in your medical record that you are using the machine and that it’s helping you.

You will pay a 20 percent coinsurance based on the Medicare-approved amount for a CPAP machine. Medicare Part B covers the other 80 percent of the cost. The Part B deductible applies.

Medicare helps pay to rent your CPAP machine for a total of 13 months, but only if you continue to use it without interruption. After 13 months of rental, you own the CPAP machine.

If you have a Medicare supplement plan (Medigap), the plan may cover your CPAP coinsurance payment for the rental period. If you have a Medicare Advantage plan (Part C), you need to check with the plan for details about what a CPAP machine would cost. Medicare Advantage plans must provide at least the same coverage as Part B, but each plan sets its own cost terms.

Does Medicare Cover CPAP Supplies?

In addition to CPAP machines, Medicare Part B’s durable medical equipment benefit also covers CPAP supplies, such as face masks, tubing and filters. Medicare Part B pays 80 percent of the Medicare-approved amount, while you pay 20 percent as coinsurance. Your coinsurance may be paid by your Medicare supplement plan, or your cost may be different if you have a Medicare Advantage plan.

Since CPAP supplies can lose effectiveness with use, Medicare covers replacement supplies on a regular schedule. Depending on the item, you may need replacements every two weeks to every six months. Talk with your doctor or supplier about scheduling replacement supplies.