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According to the National Sleep Foundation, 18 million Americans suffer from some form of sleep apnea and it affects men and women equally. If you’ve been diagnosed with sleep apnea and are enrolled in Medicare, here’s what you should know about coverage for treatment with a sleep apnea machine or other sleep apnea devices.
According to the Mayo Clinic, if lifestyle changes such as weight loss and smoking cessation don’t help your sleep apnea, the first treatment of choice is a sleep apnea machine to open up your airway while you sleep.
A continuous positive airway pressure, or CPAP machine, can be used in cases of moderate to severe sleep apnea. The sleep apnea machine is a small device you keep at your bedside. The machine generates air pressure, which is delivered through a mask covering your nose. The air pressure is slightly higher than room air, which keeps your upper airway open.
If a CPAP machine doesn’t work for you, your doctor may recommend a different sleep apnea machine known as a BPAP, which is a bi-level positive airway pressure unit. It provides more air pressure when you inhale and less when you exhale; some people tolerate this type of sleep apnea machine better than the CPAP machine. Some people have good outcomes with an oral device for sleep apnea treatment.
As a last resort, your doctor may recommend surgery to remove tissue obstructing your airway, or to remove your tonsils and adenoids. If you are extremely overweight, and the extra weight is causing severe sleep apnea, your doctor may also suggest weight loss surgery.
In most cases, Medicare generally covers 80% of the allowable charges related to a sleep apnea machine.
Medicare initially may pay for a three-month trial with a CPAP machine. After that time, Medicare may cover a longer period of treatment if you meet with your doctor and he or she determines the device or helping you. Once that information is recorded in your medical record, Medicare will generally cover an additional ten months of sleep apnea machine rental, for a total of 13 months, at which time, you will own the equipment outright. Tubing and other supplies for your sleep apnea machine are generally also covered at 80%.
You generally need to meet your Medicare Part B deductible before Medicare pays its share, and you must rent your device from a supplier enrolled in Medicare. The doctor who orders your CPAP machine must also participate with Medicare.
Medicare generally covers certain types of sleep tests your doctor orders to diagnose sleep apnea. It may also cover other types of sleep apnea machines, such as the BPAP machine. Medicare also covers certain types of oral appliance therapy with sleep apnea devices, as long as the supplier is approved with Medicare.
If you need other types of sleep apnea treatment such as surgery to remove obstructing tissue, Part A and Part B typically cover allowable charges for medically necessary care.
If you are a smoker and you need help to quit smoking, Medicare Part B covers smoking cessation sessions with a qualified provider. If your doctor suggests weight loss as part of your sleep apnea treatment, Medicare covers weight loss counseling. In some cases, if you are morbidly obese and your obesity is contributing to your sleep apnea, Medicare may cover certain types of weight loss surgery.
Nasal congestion from allergies may also contribute to sleep apnea. If you have a Medicare Part D Prescription Drug Plan, your plan should cover any prescription allergy medications and nasal sprays your doctor orders for sleep apnea treatment, but you should check your plan formulary to be sure.
To find a Medicare Advantage or Medicare Supplement plan that may cover sleep apnea equipment, enter your zip code on this page.
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