Does Medicare Cover Sleep Studies?

Sleep disorders can significantly impact health and daily life, often requiring specialized diagnostic procedures. A sleep study, also known as polysomnography, evaluates sleep patterns and detects various sleep-related conditions. Understanding whether these diagnostic tests are covered is a primary concern for many. Fortunately, Medicare offers coverage for sleep studies under specific conditions, helping beneficiaries access necessary evaluations for sleep disorders.

Medicare Coverage Fundamentals for Sleep Studies

Medicare generally covers diagnostic sleep studies when medically necessary. Medicare Part B, which covers medical insurance, is the primary source of coverage for outpatient diagnostic sleep studies. This includes in-lab polysomnography (Type I studies) and home sleep tests (Types II, III, and IV).

In-lab polysomnography involves an overnight stay in a certified sleep clinic or hospital, where medical professionals monitor physiological parameters during sleep. Home sleep tests allow individuals to conduct the study at home, using portable devices to collect data. For either study type, coverage requires a physician’s order, confirming medical need based on clinical signs and symptoms. While Medicare broadly covers sleep studies for obstructive sleep apnea (OSA), it may also cover Type I in-lab studies for other conditions like narcolepsy and parasomnia, provided certain criteria are met. However, sleep studies for chronic insomnia or routine snoring without suspected sleep apnea are typically not covered.

Qualifying for Medicare Coverage

For Medicare to cover a sleep study, medical evidence must support its necessity. This begins with a referring physician’s assessment, documenting symptoms of a sleep disorder. Common symptoms prompting a sleep study referral include loud snoring, observed pauses in breathing during sleep, and excessive daytime sleepiness.

For suspected obstructive sleep apnea, Medicare covers all types of sleep studies, from in-lab polysomnography to home sleep tests. The choice between an in-lab or home study depends on the suspected complexity of the sleep disorder or co-morbid conditions; home sleep tests are often the initial diagnostic step for suspected OSA. For other conditions like narcolepsy or parasomnia, Medicare usually limits coverage to Type I in-lab studies, requiring proof that the condition significantly affects health or that seizures are suspected. Physician documentation must include findings such as an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) meeting specific thresholds for medical necessity. Medicare may also cover follow-up sleep studies to assess treatment effectiveness, evaluate changes after significant weight fluctuations, or address unsuccessful initial treatments.

Costs Associated with Sleep Studies

Individuals with Original Medicare (Parts A and B) will incur out-of-pocket expenses for covered sleep studies. After satisfying the annual Medicare Part B deductible, which is $257 in 2025, beneficiaries are typically responsible for 20% of the Medicare-approved amount for the sleep study. The cost of these diagnostic tests can vary significantly; in-lab sleep studies generally range from $1,000 to $3,500, while home sleep tests are often more affordable, costing a few hundred dollars.

The specific amount an individual pays can also depend on the type of facility where the sleep study is performed. For example, a sleep study conducted in a hospital outpatient department might involve a copayment in addition to the 20% coinsurance. Confirming the healthcare provider and facility accept Medicare assignment is important. Accepting assignment means the provider agrees to the Medicare-approved amount as full payment, preventing unexpected higher charges.

For those enrolled in a Medicare Advantage (Part C) plan, costs may differ, but these plans must provide at least the same coverage as Original Medicare. Individuals with Medicare Supplement (Medigap) plans may find these policies cover some or all remaining out-of-pocket costs, such as coinsurance and deductible.

Steps to Obtain a Covered Sleep Study

Obtaining a Medicare-covered sleep study begins with a consultation with a primary care physician. During this visit, the physician will evaluate the individual’s symptoms and medical history to determine if a sleep disorder is suspected. Based on this assessment, the physician will issue a referral or order for a sleep study, documenting the medical necessity for the test.

Next, individuals should choose a Medicare-approved facility or provider for their sleep study. These facilities must be certified or affiliated with a hospital, or operate under the direction and control of a physician. Confirming that the chosen facility accepts Medicare assignment is an important step to help manage potential out-of-pocket expenses.

Once the facility is selected, the sleep study can be scheduled. For a home sleep test, this typically involves receiving instructions and equipment to use at home, which is then returned for interpretation. For an in-lab study, individuals will spend a night at the facility, where sensors will monitor various physiological functions during sleep. Following the completion of the study, the results will be interpreted by a sleep specialist, and a follow-up appointment with the referring physician will be scheduled to discuss the findings and determine any subsequent steps.