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Medicare Requirements for CPAP Reimbursements

A continuous positive airway pressure (CPAP) device is designed to help individuals who temporarily stop breathing while sleeping. This condition is medically termed obstructive sleep apnea. An individual with obstructive sleep apnea may stop breathing 5 to 30 times each hour during the course of sleep, according to the Mayo Clinic. Sleep apnea is diagnosed through a comprehensive sleep study. Medicare patients are qualified for a CPAP machine reimbursement when they meet certain criteria.

  1. Documentation

    • Before Medicare approves reimbursement on CPAP equipment, the patient must undergo a documented sleep study. The sleep study must be performed by an accredited sleep study center. The sleep study must record sleep for at least two hours. Patients must also present a signed prescription from their physician for CPAP equipment, along with the parameter settings for the CPAP machine.

    AHI

    • The Apnea Hypopnea Index (AHI) tells exactly how many times the patient has stopped breathing during the course of sleep. Medicare requires that AHI exceed 15 episodes an hour during the course of sleep for reimbursement.

    Co-payment

    • As of 2008-2009 Medicare requires patients to pay a non-negotiable co-payment of $135. This co-payment must be paid in full before reimbursement of CPAP equipment.

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