How Initial Use Determines Insurance Payment for Ongoing CPAP Therapy

Early Compliance Is Key to Keeping the Device

CPAP masks
Insurance coverage depends on early usage compliance for ongoing supplies. Rachel Tayse/Flickr/CC BY 2.0

If you are new to using continuous positive airway pressure (CPAP) 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? 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 adjusting.

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 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. Many insurance policies will cover 80 to 90 percent of the cost of DME, including CPAP, after you have met your deductible.

Initial Lease of CPAP Equipment Converts to Ownership

Insurers do not want to pay for medical equipment that is not being used. Therefore, most will initially lease the CPAP machine for you. This will allow you an opportunity to demonstrate that the treatment is tolerable and effective for you. Unfortunately, a lot of people do not overcome initial problems getting used to CPAP.

Therefore, many people do not use the therapy long term, even though it can be extremely effective if it is tolerated. After a lease period that typically lasts 13 months, the insurer will have completely paid for the machine and you will own it outright.

Usage Monitoring Helps to Ensure Adequate Compliance

During the first few months, the insurer will want to keep tabs on you to make certain you are one of the patients who can tolerate it.

If it sits in your closet gathering dust, this doesn’t help treat your condition and it wastes the insurance company’s money. Newer CPAP devices have a modem or an SD card that collects data on your use through monitoring. This can be used to generate a report that tells how much you use the device. This data is used to dictate payment for the machine.

In general, you must use your CPAP at least 4 hours per night, 70 percent of the nights for insurance companies to pay for the device. This criterion is based on Medicare’s standard that, in turn, is based on studies that show at least 4 hours of use are required for the cardiovascular benefit of treatment. This compliance is typically measured over a continuous period of 30 days within the first 3 months that you have the CPAP. In addition, you must 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 that compliance threshold, or it simply is not helping you, the insurer will demand that the machine be returned to the DME provider and will not pay for it.

Reach Out for Help if You Are Struggling With CPAP Use

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.

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