What Medicare covers for Inspire

Medicare Part B covers Inspire, a surgically implanted device that treats obstructive sleep apnea, but only if you meet specific medical and procedural requirements. The device works by delivering mild electrical pulses to keep your airway open while you sleep. Medicare will pay for both the surgery to place it and the device itself if your doctor documents that you have moderate to severe sleep apnea, have tried and failed a CPAP machine, and meet other clinical criteria.

Coverage is not automatic. Your doctor must submit documentation to Medicare before surgery, and Medicare reviews the case to confirm you meet their coverage rules. If Medicare denies the request, you have the right to appeal. The process typically takes several weeks, so plan ahead if you are considering this treatment.

Key Takeaways

  • Medicare Part B covers Inspire surgery and the device itself if you have moderate to severe obstructive sleep apnea and have tried CPAP therapy first.
  • Your doctor must submit medical records and test results to Medicare before surgery for a coverage decision, which usually takes two to four weeks.
  • You will owe the Part B deductible and 20 percent coinsurance after Medicare pays its share, unless you have a Medigap or Medicare Advantage plan that covers additional costs.
  • If Medicare denies coverage, you can request an appeal and ask your doctor to provide additional clinical information to support the case.

Medical requirements Medicare uses to decide coverage

Medicare requires that you have a diagnosis of moderate to severe obstructive sleep apnea, confirmed by a sleep study. The sleep study must show an apnea-hypopnea index (AHI) score of 15 or higher, which measures how many times per hour your breathing stops or becomes shallow. Your doctor will order this test if you have not had one recently.

You must also have tried continuous positive airway pressure (CPAP) therapy for at least four weeks and found it ineffective or intolerable. Medicare considers this a required step before approving Inspire. Your sleep specialist will document why CPAP did not work for you — whether you could not tolerate the mask, the pressure settings, or the machine itself. This documentation becomes part of the coverage request sent to Medicare.

You cannot have certain anatomical features that would make Inspire less likely to work. Your doctor will examine your airway during an office visit to rule out conditions like a very narrow airway opening or certain throat abnormalities. If your anatomy is suitable, your doctor will note this in the medical record.

How the Medicare approval process works

Your sleep specialist or surgeon will gather your sleep study results, CPAP trial records, and a detailed clinical note explaining why Inspire is appropriate for you. They submit these documents to Medicare along with a request for coverage. This is called a prior authorization request. Medicare's medical review team examines the documents to confirm you meet the coverage criteria.

The review typically takes 10 to 14 business days. Medicare will send a decision letter to your doctor's office and a copy to you. If Medicare approves, the letter will state that the surgery and device are covered. If Medicare denies the request, the letter will explain the reason — for example, that your sleep study results do not meet the severity threshold, or that your CPAP trial was not long enough.

Do not schedule surgery until you have received an approval letter from Medicare. If you have surgery before Medicare approves coverage, you may be responsible for the full cost of the device and procedure, which can exceed $30,000.

Your out-of-pocket costs under Medicare Part B

Once Medicare approves and covers Inspire, you will owe the Part B deductible if you have not met it for the year. For 2024, the Part B deductible is $240. After you meet the deductible, Medicare pays 80 percent of the approved amount for the surgery and device, and you pay 20 percent coinsurance.

The actual coinsurance amount depends on what your surgeon's practice charges and what Medicare's approved amount is for your area. Surgeons can charge more than Medicare's approved amount, and you may owe the difference if your surgeon does not accept Medicare assignment. Before surgery, ask your surgeon's billing office whether they accept Medicare assignment and what your estimated coinsurance will be.

If you have a Medigap (supplemental insurance) plan, it may cover some or all of your coinsurance. If you have a Medicare Advantage plan, your out-of-pocket costs depend on your plan's rules — some plans cover Inspire fully after a copay, while others require coinsurance. Check your plan documents or call your plan's customer service line to learn your exact costs before moving forward.

What to do if Medicare denies coverage

If Medicare denies your request, you have the right to appeal. The appeal process has multiple levels. First, you can request a redetermination, which means Medicare will review the same documents again. Your doctor can submit additional clinical information to support the case — for example, detailed notes about why CPAP failed or test results showing you are a good candidate for Inspire.

If the redetermination is also denied, you can request a reconsideration, which involves an independent Medicare contractor reviewing the case. This step can take 30 to 60 days. If you disagree with that decision, you can request a hearing before an administrative law judge, though this process is lengthy and most cases are resolved at the redetermination or reconsideration stage.

Ask your doctor's office to help you with the appeal. They know your medical history and can write a strong letter explaining why Inspire is medically necessary for you. Many practices have staff who handle Medicare appeals regularly and understand what additional information Medicare typically needs to reverse a denial.

Inspire versus CPAP: why Medicare requires CPAP first

CPAP therapy is the standard first treatment for obstructive sleep apnea because it works well for many people and costs far less than Inspire. Medicare requires you to try CPAP for at least four weeks before approving Inspire because the agency wants to confirm that CPAP truly does not work for you. Some people need time to adjust to CPAP, and a longer trial might succeed.

If you tried CPAP years ago and it did not work, you may still need to try it again before Inspire. Medicare's rule is based on your most recent trial. If your previous CPAP trial was more than a year or two ago, your sleep specialist may recommend a new trial with updated equipment or mask styles, since CPAP technology has improved. Discuss with your doctor whether a new trial makes sense for you or whether your previous trial is recent enough to satisfy Medicare's requirement.

Questions to ask your sleep specialist or surgeon

Before pursuing Inspire, ask your doctor these questions: Do my sleep study results and CPAP trial meet Medicare's requirements? Will you submit a prior authorization request to Medicare, and how long will that take? What is your practice's experience with Inspire, and how many procedures have you performed? What is your estimated charge for the procedure, and do you accept Medicare assignment?

Also ask: What happens if Medicare denies coverage — will you help me appeal? What are the risks and benefits of Inspire compared to other treatments? Are there any anatomical reasons why Inspire might not work well for me? And finally: If I move forward, when can surgery be scheduled, and what is the recovery time?

Frequently Asked Questions

Does Medicare Advantage cover Inspire the same way Part B does?

Medicare Advantage plans must cover Inspire if Original Medicare covers it, but your out-of-pocket costs may differ. Some Advantage plans cover Inspire with a copay, while others require coinsurance or have higher deductibles. Contact your plan directly to learn your specific coverage and costs before scheduling surgery.

What if I do not have a sleep study yet?

You will need a sleep study to confirm obstructive sleep apnea and measure your AHI score. Medicare will not approve Inspire without one. Your primary care doctor or sleep specialist can order a home sleep test or an in-lab study. The results typically come back within one to two weeks.

Can I use Inspire if I have never tried CPAP?

Medicare requires a CPAP trial of at least four weeks before approving Inspire. If you have never used CPAP, you will need to try it first. Your sleep specialist can prescribe a CPAP machine and arrange follow-up visits to monitor your tolerance and adjust settings. If CPAP truly does not work after four weeks, your doctor can then request Inspire coverage from Medicare.

How long does Inspire last, and does Medicare cover replacement?

The Inspire device battery lasts approximately 10 years. When the battery runs out, you will need a replacement procedure. Medicare covers the replacement surgery and new device if you continue to meet medical criteria. The replacement process is similar to the original approval — your doctor will submit documentation, and Medicare will review it.

What if my surgeon charges more than Medicare's approved amount?

If your surgeon does not accept Medicare assignment, you may owe the difference between their charge and Medicare's approved amount, in addition to your coinsurance. Ask your surgeon's billing office in advance whether they accept Medicare assignment. If they do not, ask for an estimate of the total charge so you know your full out-of-pocket cost before surgery.