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Medicare CPAP Regulations

Many people struggle with sleep apnea. Thus condition is a real medical concern and can keep an individual from achieving quality sleep. As the body realizes that there is not enough oxygen in the blood, the brain arouses the body out the deep sleep to take a deep breath and replenish the oxygen. As a result, REM sleep can be hard to achieve, resulting in the patient feeling tired. Continual Positive Airway Pressure ,or CPAP, machines are designed to assist the patient by keep their airway open and the breath flowing freely. However, patients who are covered by Medicaid must meet Medicaid regulations and requirements before the equipment will be covered.

  1. In-Person Evaluations

    • Medicare will not cover the costs associated with the use of CPAP equipment unless proper evaluations have been completed prior to starting the use of a CPAP. An in-person sleep evaluation must be completed prior to a patient completing a sleep study. Failure to complete the evaluation will prevent Medicaid from paying for the CPAP treatment for sleep apena. As part of the overall evaluation, the patient must also perform an unattended home sleep study with a home sleep monitoring device which will record the patient's breathing patterns.

    Re-evaluation

    • Once the first 12 weeks of treatment is over, the patient must be re-evaluated in order to continue treatment and use of the CPAP under Medicaid. The re-evaluation must be completed within first eight weeks after the first 12-week treatment period has ended. A patient will need to go in for another evaluation and complete another unattended home sleep study using a sleep monitoring device. Compliance forms must be completed prior to the sleep study or the claims will be denied by Medicaid.

    Coverage Limits

    • CPAP coverage by Medicaid is limited to a period of 12 weeks for patients who have been diagnosed with obstructed sleep apnea (OSA). If the patient's condition of OSA improved during the 12 weeks of using a CPAP, it is possible to get the coverage limits increased to enable the patient to continue to use the CPAP.

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