CPAP Machines

Most health insurance plans consider CPAP and BiPAP machines to be Durable Medical Equipment (DME). While coverage varies, most insurers follow a similar process to ensure the treatment is medically necessary.

• Doctor’s Visit and Prescription: You must first consult with a doctor to discuss your sleep apnea symptoms. They will then prescribe a sleep study to confirm a diagnosis. A sleep study can be done at an overnight lab or with an at-home kit.

• Compliance Period: Many insurers require a trial period (typically 30-90 days) during which you must demonstrate consistent usage of the machine. The common requirement is using the device for at least 4 hours per night, on at least 70% of nights. Your CPAP machine often has built-in features to track this data. If you don’t meet these requirements, the insurer may not continue coverage.

• Cost Sharing: You will typically be responsible for a portion of the cost through a copay, coinsurance, or by meeting your deductible. Some plans may require you to rent the machine for a set period (e.g., 10-13 months) before you own it.

Medicare Coverage

Medicare Part B covers 80% of the Medicare-approved cost for CPAP and BiPAP machines as DME. The Part B deductible applies.

• Initial Coverage: After diagnosis, Medicare covers the machine for a three-month trial period. If your doctor confirms the therapy is helping, coverage continues.

• Rental-to-Ownership: You rent the machine for 13 months. Medicare pays its 80% share, and you are responsible for the remaining 20%. After 13 months of continuous rental payments, you own the machine.

• Replacement: Medicare generally covers a new CPAP machine every five years.

• Supplies: Medicare also covers replacement supplies on a set schedule (e.g., a new mask every three months, new tubing every three months, and new filters every one to six months depending on the type).

NC Medicaid Coverage

North Carolina Medicaid also covers CPAP and BiPAP machines and related supplies for individuals diagnosed with sleep apnea.

• Prior Approval: NC Medicaid requires a prior approval from a doctor to get coverage.

• Initial Rental Period: The initial approval and coverage for a CPAP or BiPAP machine is for a six-month rental period.

• Continued Coverage: After the first five months of therapy, your doctor must submit a statement to NC Medicaid indicating that the device is still medically necessary and that you are continuing to use it. If this is not done, continued coverage may be denied.

• Sleep Studies: NC Medicaid covers both in-lab and at-home sleep studies for a sleep apnea diagnosis.

Private Health Insurance

Most private health insurance plans, including those from providers like Blue Cross Blue Shield of North Carolina, cover CPAP and BiPAP machines.

• Varying Requirements: Coverage details, including deductibles, copays, coinsurance, and specific compliance requirements, can vary widely between plans.

• Prior Authorization: Many private plans, including some Medicare Advantage plans, require your doctor to get a prior authorization before they will cover a sleep study or the machine.

• In-Network Providers: Your plan may require you to use an in-network DME supplier to ensure maximum coverage and minimize out-of-pocket costs. Always check with your insurance provider to understand their specific policy.

Sleep apnea is a potentially serious sleep disorder in which a person’s breathing repeatedly stops and starts while they sleep. This can happen from a few times to hundreds of times a night, preventing the body from getting enough oxygen and disrupting restorative sleep.

The main types of sleep apnea are:

• Obstructive Sleep Apnea (OSA): This is the most common type. It occurs when the muscles in the back of the throat relax, causing the airway to narrow or close. This physical blockage prevents air from flowing into the lungs, causing a person to snort, gasp, or choke as their brain briefly wakes them to reopen the airway.

   
   
   

• Central Sleep Apnea (CSA): This less common form happens when the brain fails to send the proper signals to the muscles that control breathing. This means the person makes no effort to breathe for a short period. CSA is often linked to underlying medical conditions like heart failure or stroke.

   
   
   

• Complex Sleep Apnea Syndrome: This is a combination of both obstructive and central sleep apnea.

   

Common Signs and Symptoms

The signs of sleep apnea can be noticed by you or a partner and often include:

• Loud snoring (a common sign of OSA)

   

• Gasping for air during sleep

   

• Waking up with a dry mouth or headache

   

• Excessive daytime sleepiness, fatigue, or irritability

   

• Difficulty concentrating

   

• Insomnia

   

How is Sleep Apnea Treated?

Treatment for sleep apnea depends on the type and severity of the condition.

• Lifestyle Changes: For milder cases, doctors may recommend lifestyle adjustments such as losing weight, exercising regularly, quitting smoking, and avoiding alcohol or sedatives before bed. Sleeping on your side rather than your back can also help.

   
   

• Positive Airway Pressure (PAP) Therapy: This is the most common and effective treatment for moderate to severe sleep apnea. A machine delivers a stream of pressurized air through a mask worn over the nose or mouth while sleeping. The air pressure keeps the airway open, allowing for normal breathing.

   

  • CPAP (Continuous Positive Airway Pressure): Provides a constant, steady flow of air pressure.

  • BiPAP (Bilevel Positive Airway Pressure): Delivers higher pressure when you inhale and lower pressure when you exhale, which can be more comfortable for some people.

     

• Oral Appliances: A dentist can create a custom-fitted oral appliance that is worn like a mouthguard. These devices work by repositioning the jaw and/or tongue to keep the airway open.

   
   

• Surgery: In some cases, surgery may be an option, particularly if other treatments have been unsuccessful. Surgical procedures can involve removing excess tissue from the throat or repositioning the jaw to improve airflow.