How Often Will Medicare Replace a CPAP Machine?

Continuous Positive Airway Pressure (CPAP) machines provide a common treatment for individuals experiencing sleep apnea, a condition where breathing repeatedly stops and starts during sleep. Medicare can offer coverage for these devices and their associated supplies. Understanding the specific guidelines for initial coverage and subsequent replacement is important for beneficiaries.

Medicare Coverage for CPAP Devices

Medicare Part B covers medically necessary durable medical equipment (DME), which includes CPAP machines, under specific conditions. DME is defined as equipment that can withstand repeated use, is used for a medical reason, is typically only useful to someone who is sick or injured, is used in the home, and is expected to last at least three years. For CPAP coverage, a diagnosis of obstructive sleep apnea (OSA) is required, typically confirmed through a qualified sleep study. This diagnosis must be accompanied by a prescription from a treating physician who participates in Medicare.

Medicare generally initiates coverage with a three-month trial period for the CPAP device and necessary accessories. During this period, beneficiaries must demonstrate consistent usage, often defined as at least four hours per night on 70% of nights within a consecutive 30-day period. Following the trial, continued coverage depends on a physician’s documentation that the therapy is effective and that the beneficiary continues to adhere to usage requirements.

Medicare typically pays 80% of the Medicare-approved amount for the equipment after the beneficiary has met their annual Part B deductible. For 2025, the Part B deductible is $257. The remaining 20% is the beneficiary’s coinsurance responsibility.

Replacement Schedule for CPAP Machines

Medicare’s standard policy for replacing a CPAP machine is generally every five years. A new doctor’s order and medical necessity documentation are required for any replacement, even after the five-year period has passed.

There are specific circumstances under which Medicare may cover an earlier replacement of a CPAP machine. If the machine is no longer functional and cannot be repaired, or if the cost of repair exceeds established limits, a replacement may be allowed. Documentation of irreparable damage is necessary. An early replacement may also be considered if the machine is lost or stolen, provided there is proper documentation, such as a police report.

A significant change in the patient’s medical condition that necessitates a different type of device, such as transitioning from a CPAP to a BiPAP machine, can also trigger an early replacement. Additionally, if a manufacturer issues a recall for the device due to safety or performance issues, Medicare may cover a replacement sooner than the five-year guideline. In all cases of early replacement, updated medical documentation and a new prescription from the treating physician are required to support the claim.

Replacement Schedule for CPAP Supplies

CPAP accessories and supplies require regular replacement due to wear and tear, hygiene considerations, and to maintain the effectiveness of the therapy. Medicare provides specific guidelines for how often various supplies can be replaced. These schedules help ensure beneficiaries have functional and hygienic equipment for their ongoing treatment.

Masks, including full face, nasal, and nasal pillow masks, are typically eligible for replacement every three months. The mask cushion or pillow, which comes into direct contact with the face, often needs replacement more frequently, usually twice a month or monthly. Headgear, which secures the mask, can generally be replaced every six months.

Tubing or hoses that connect the mask to the machine are typically replaced every three months to prevent bacterial buildup and ensure proper airflow. Filters, both disposable and non-disposable, also have set replacement schedules; disposable filters are usually replaced twice a month, while non-disposable filters are replaced every six months. For machines with humidifiers, the water chamber is typically replaced every six months. These specific replacement frequencies are general guidelines, and individual medical necessity or specific plan rules may lead to slight variations.

The Replacement Process

Obtaining a replacement CPAP machine or supplies begins with contacting the durable medical equipment (DME) supplier that originally provided the equipment. This supplier is typically familiar with Medicare’s billing and documentation requirements. The beneficiary should communicate their need for replacement items and inquire about the necessary steps.

The role of the treating physician is central to the replacement process. A new prescription or updated documentation of continued medical necessity may be required, especially for a machine replacement or if there have been changes in the beneficiary’s condition. The physician’s office often works in conjunction with the DME supplier to provide the required paperwork to Medicare.

The DME supplier will verify Medicare eligibility and ensure that the request for replacement aligns with Medicare’s coverage criteria and replacement schedules. Once approved, the supplier will arrange for the ordering and delivery of the replacement items. If issues arise or a claim is denied, beneficiaries have the right to appeal Medicare’s decision, and the DME supplier or physician’s office can often provide guidance through this process.