How Initial Use Determines Insurance Payment for Ongoing CPAP Therapy

Early Compliance Is Key to Keeping the Device

If you are new to using continuous positive airway pressure (CPAP) therapy to treat your sleep apnea, you may want to learn more about your goals of use in order to obtain insurance payment for your machine. How does initial compliance determine whether insurance pays for CPAP therapy? Learn how the first few months of use are critical to ensuring long-term access to the treatment and what to do if you struggle to adjust.

CPAP masks on display
Rachel Tayse / Flickr / CC BY 2.0

Review Your Insurance Coverage of Durable Medical Equipment

First, it is important to understand your individual insurance situation. This may be best accomplished by contacting your health insurance provider and speaking about your benefits. In most cases, CPAP therapy is covered under the durable medical equipment (DME) provision of insurance. This coverage also pays for everything from wheelchairs to hospital beds to oxygen concentrators. The level of coverage depends on your specific insurance policy. For instance, Medicare will pay 80% of the Medicare-approved amount for a CPAP device after you have met your Part B deductible.

Initial Lease Converts to Ownership

Although CPAP therapy is the most effective treatment for sleep apnea, many people are unable to overcome the initial challenges associated with CPAP therapy and quickly abandon treatment. Insurers do not want to pay for medical equipment that is not being used. Therefore, most insurers first give you a three-month trial to test out the device. If, at the end of this trial period, you and your healthcare provider discover that the treatment is tolerable and effective, your insurer will often pay your monthly rental fee. Check with your individual provider to find out their particular coverage benefits.

Usage Monitoring Helps to Ensure Adequate Compliance

During an initial three-month trial period, insurance companies may keep tabs on you to make certain that you are using your CPAP device and that it works for you before they will pay for it. If it sits in your closet gathering dust, this doesn’t help treat your condition, and it wastes the insurance company’s money.

Most CPAP devices have built-in SD cards that store a variety of usage information, including how many hours you have used your device and how many days you have used your device for at least four hours. Newer devices have built-in modems that use Wi-Fi, Bluetooth, or cellular service to automatically transmit your data to your healthcare provider and health insurer.

Many insurance compliance guidelines require that you use your CPAP machine for four or more hour/night during 70% of the nights within the first 90 days of therapy. This criterion is based on studies that show at least four hours of use are required for the cardiovascular benefit of treatment.

In addition, insurers may require you to check in with your sleep specialist, who will assess your response to treatment and ensure you are deriving a benefit. If you are unable to meet this compliance threshold, or if the device is simply not helping you, the insurer may demand that the machine is returned to the DME provider and may not pay for it.

Reach Out for Help If You Are Struggling

Some people struggle with getting a proper CPAP mask fit or overcoming other initial problems. For this reason, it is very important that you be in close contact with your DME provider and sleep specialist to find solutions. If you are simply unable to tolerate it, there may be alternative treatments available to you, including bilevel therapy, an oral appliance, or surgery.

Do everything you can to meet your use requirements early in the treatment. By using the device as much as you sleep, you will further experience greater improvement in your sleep quality. If you struggle, don’t hesitate to reach out to your providers to remedy the situation so that you don’t miss out on the opportunity to have your condition treated and your insurance pay for it.

3 Sources
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  1. Centers for Medicare and Medicaid Services website. Decision Memo for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA) (CAG-00093N).

  2. Bakker JP, Weaver TE, Parthasarathy S, Aloia MS. Adherence to CPAP: What Should We Be Aiming For, and How Can We Get There? Chest. 2019;155(6):1272-1287. doi:10.1016/j.chest.2019.01.012

  3. Schwab RJ, Badr SM, Epstein LJ, et al. An official American Thoracic Society statement: continuous positive airway pressure adherence tracking systems. The optimal monitoring strategies and outcome measures in adults. Am J Respir Crit Care Med. 2013;188(5):613-620. doi:10.1164/rccm.201307-1282ST

By Brandon Peters, MD
Brandon Peters, MD, is a board-certified neurologist and sleep medicine specialist.