Does Medicare Pay for a CPAP Machine?
Understand how Medicare covers CPAP machines, including eligibility, acquisition, and cost-sharing for this essential medical equipment.
Continuous Positive Airway Pressure (CPAP) machines provide an effective treatment for obstructive sleep apnea (OSA), a condition where breathing repeatedly stops and starts during sleep. Understanding Medicare coverage for CPAP machines and related supplies is important for managing healthcare costs and ensuring access to necessary therapy.
Medicare Coverage for CPAP Machines
Medicare Part B, which covers outpatient medical services and durable medical equipment (DME), provides coverage for CPAP machines. These machines deliver a continuous stream of air pressure through a mask worn during sleep, keeping the airway open and preventing breathing interruptions. Coverage is contingent upon the machine being medically necessary for diagnosed obstructive sleep apnea.
Criteria for Medicare Approval
For Medicare to approve coverage, a beneficiary must first receive an obstructive sleep apnea (OSA) diagnosis. This requires a sleep study, conducted either in a sleep laboratory or at home. Results must show an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) score of 15 or more events per hour, or between 5 and 14 events per hour with documented symptoms like excessive daytime sleepiness, impaired cognition, or hypertension. A doctor’s prescription is also required, confirming medical necessity. The prescribing doctor must be enrolled in Medicare, and a face-to-face evaluation must occur before the sleep test to assess for OSA symptoms.
Medicare covers a three-month trial period for CPAP therapy, including the machine and necessary accessories. To continue coverage beyond this trial, the beneficiary must demonstrate compliance. This means using the CPAP machine for at least four hours per night on 70% of nights within a consecutive 30-day period. A follow-up face-to-face visit with the doctor is required between 31 and 91 days after starting therapy, where the physician documents treatment effectiveness and compliance.
The Process of Acquiring a CPAP Machine
Once medical criteria for CPAP machine coverage are met, the process of acquiring the device involves working with a Medicare-approved Durable Medical Equipment (DME) supplier. Ensure both the prescribing doctor and the DME supplier participate in Medicare and accept assignment to prevent unexpected charges. The DME supplier will then submit claims directly to Medicare on the beneficiary’s behalf for the CPAP machine and its initial accessories.
Medicare’s coverage for the CPAP machine begins with a rental period. After an initial three-month trial, if the therapy is successful and compliance requirements are met, Medicare will continue to cover the machine’s rental costs for a total of 13 continuous months. After Medicare has made rental payments for these 13 months, the beneficiary will own the CPAP machine.
Costs and Ongoing Maintenance
Beneficiaries with Original Medicare (Part B) are responsible for out-of-pocket costs related to their CPAP machine. After meeting the annual Medicare Part B deductible ($257 for 2025), beneficiaries pay 20% of the Medicare-approved amount for the CPAP machine rental and related services. Medicare pays the remaining 80% of the approved amount.
Medicare Part B also covers ongoing replacement supplies for the CPAP machine, provided the beneficiary meets compliance requirements. These supplies, including masks, tubing, and filters, have specific replacement schedules. Mask cushions and nasal pillows may be replaced every two weeks to one month. Full masks and tubing are typically replaced every three months. Disposable filters are often replaced twice a month, and non-disposable filters or headgear usually every six months.
The CPAP machine itself has an expected lifespan of five to seven years. Medicare may cover a replacement sooner if there is documented evidence of loss, theft, irreparable damage, or if repair costs exceed established limits.