Does Medicare cover CPAP for sleep apnea?

Sleep apnea is common in older adults, badly under-diagnosed, and genuinely dangerous — it drives high blood pressure, atrial fibrillation, stroke risk and the kind of daytime exhaustion that gets mistaken for depression or dementia. The treatment works. Medicare pays for it. And a startling number of people lose the coverage in month four because nobody explained the rule to them.

This guide is mostly about that rule, because everything else in the process is straightforward.

Medicare will not cover a CPAP machine without a diagnosis, and the diagnosis has to come from a sleep study ordered by the doctor. There are two kinds and both are covered:

• A home sleep apnea test — a small device your parent wears overnight in their own bed. Cheaper, easier, and increasingly the default for straightforward cases.
• An in-lab polysomnography — an overnight stay in a sleep center with full monitoring. Used where the picture is complicated, where other sleep disorders are suspected, or where a home test was inconclusive.

For an older adult with mobility problems or dementia, push for the home test. A confused patient wired up in an unfamiliar sleep lab produces a bad study and a miserable night.

Once apnea is diagnosed, Medicare authorizes an initial 12-week trial of CPAP. The machine arrives from a Medicare-enrolled durable medical equipment supplier, and Part B pays 80% of the approved rental amount after the deductible.

The trial is not a formality. It is the period during which Medicare decides whether to keep paying, and two things have to happen before it ends.

1. 1.A face-to-face follow-up visit with the treating doctor, between the 31st and 91st day of therapy, at which the doctor documents that the symptoms are improving and the patient is benefiting from the machine. This visit is the one people forget. No visit, no continued coverage, regardless of how well the therapy is going.
2. 2.Documented adherence. Modern CPAP machines transmit usage data to the supplier automatically. Medicare's standard is use for at least four hours per night on at least 70% of nights during a consecutive 30-day period within the first three months — in practice, 21 nights out of 30.

Medicare does not buy a CPAP machine outright. It rents it. Part B pays its share of a monthly rental for 13 months of continuous use, after which ownership transfers to your parent and the rental payments stop. The supplier is responsible for maintaining and repairing the machine during the rental period.

Two practical consequences. First, if your parent switches suppliers mid-rental, the clock can restart — so change suppliers only for a good reason. Second, the supplier must be enrolled in Medicare and, for most areas, must be a contracted supplier. Using one that is not means paying the whole bill.

Masks, cushions, headgear, tubing and filters wear out, and dirty or ill-fitting supplies are one of the main reasons people abandon therapy. Medicare covers replacements on a defined schedule — different items on different cycles, ranging from twice a month for cushions and filters down to every few months for masks, headgear and tubing.

Most suppliers will ship replacements automatically if your parent is enrolled in their resupply program, but plenty of patients are using a mask cushion that is a year old because nobody told them they were entitled to a new one. Call the supplier and ask what is due.

Some people genuinely cannot tolerate CPAP, and there are covered alternatives — but they generally require documenting that CPAP was tried first.

• BiPAP, which uses different pressures for breathing in and out and is often easier to tolerate, is covered when CPAP has been tried and found ineffective or intolerable.
• Oral appliances made by a dentist to reposition the jaw can be covered under Part B as durable medical equipment for obstructive sleep apnea in appropriate cases — one of the few times a dentist's device is covered.
• Implanted nerve stimulation devices are covered for a narrow group of patients who meet specific criteria after CPAP failure.
• Surgery is covered in specific anatomical situations, though it is rarely the first answer in older adults.

Most of what goes wrong here is scheduling and paperwork, which is exactly the failure mode a navigator exists for. We make sure the sleep study gets ordered and read, that the 31-to-91-day follow-up visit is actually on the calendar before it is too late, that the supplier has the documentation Medicare will ask for, and that the resupply shipments are coming. And when a parent tells us the mask is intolerable, we get it changed rather than letting them quietly stop using it.