Does Medicare Cover Sleep Apnea Tests?

Sleep apnea is a common health condition characterized by interrupted breathing during sleep, which can lead to various health complications. Many individuals rely on Medicare for their healthcare needs, including the diagnosis and management of such conditions. Understanding Medicare’s coverage for sleep apnea testing is important for beneficiaries.

Understanding Medicare’s Coverage for Sleep Apnea Tests

Medicare generally covers sleep apnea tests when a healthcare provider determines them medically necessary. Medicare Part B covers these diagnostic services. Covered tests include in-facility polysomnography (PSG) and various home sleep apnea tests (HSATs).

Polysomnography, a Type I study, involves an overnight stay in a sleep clinic where multiple physiological parameters are monitored. Home sleep apnea tests, categorized as Type II, III, and IV studies, allow individuals to conduct the test at home using portable monitoring devices. These tests measure parameters like breathing patterns, heart rate, and oxygen saturation. Medicare covers these tests to screen for obstructive sleep apnea when a beneficiary exhibits clinical signs and symptoms. Medical evidence, such as physician exams and laboratory results, confirms the need for diagnostic testing.

Meeting Coverage Criteria for Sleep Apnea Tests

For Medicare to cover a sleep apnea test, a physician must order it following a thorough clinical evaluation. This evaluation includes a detailed medical history and physical examination. The physician’s assessment documents symptoms indicative of obstructive sleep apnea, establishing medical necessity for the test.

Common symptoms include excessive daytime sleepiness, loud snoring, or observed pauses in breathing during sleep. Additional signs that may warrant a test include choking or gasping during sleep, a high body mass index (BMI), or a large neck circumference. The physician’s order must be maintained in the medical record, and the testing facility must be Medicare-approved. Proper documentation supporting medical necessity is essential to ensure coverage.

Patient Costs and Financial Considerations

Medicare beneficiaries have financial responsibilities for sleep apnea tests. Under Original Medicare Part B, after meeting the annual deductible, Medicare generally pays 80% of the Medicare-approved amount for covered services. The beneficiary is responsible for the remaining 20% coinsurance. For 2025, the Part B deductible is $257.

Medicare Advantage Plans (Part C) must cover at least the same services as Original Medicare Part A and Part B, including sleep apnea tests. However, specific cost-sharing rules, such as premiums, deductibles, and coinsurance, vary by plan. Beneficiaries with Medigap policies, also known as Medicare Supplement Insurance, may find these plans help cover the coinsurance portion of their Medicare-approved bills.

Steps to Get a Covered Sleep Apnea Test

Initiating the process for a Medicare-covered sleep apnea test begins with consulting a primary care physician. Individuals should discuss symptoms such as persistent daytime fatigue, loud snoring, or observed breathing interruptions during sleep. The physician will conduct an evaluation to determine if a sleep study is appropriate and medically necessary. If indicated, the doctor will order the specific type of sleep test, whether in-lab polysomnography or a home sleep apnea test.

Ensure both the ordering physician and the testing facility accept Medicare assignment. Accepting assignment means the provider agrees to accept the Medicare-approved amount as full payment. After the test is ordered, the facility will provide instructions for scheduling and preparing for the study. For home sleep apnea tests, individuals receive guidance on how to properly set up and use the portable monitoring device.

Coverage for Sleep Apnea Treatment and Equipment

Upon diagnosis of sleep apnea following a covered test, Medicare extends coverage to medically necessary treatment options. The most common treatment is Continuous Positive Airway Pressure (CPAP) therapy, which involves using a machine to maintain open airways during sleep. Medicare Part B covers the rental or purchase of CPAP machines and related supplies as durable medical equipment (DME). This includes items like masks, tubing, and filters.

Initially, Medicare may cover a three-month trial period for CPAP therapy. If the physician documents the therapy is effective and the individual consistently uses the machine, Medicare may continue to cover costs. Beneficiaries are responsible for their Part B deductible and 20% coinsurance for CPAP equipment and supplies, similar to diagnostic tests. After a rental period, typically 13 months, Medicare beneficiaries may own the CPAP machine.