What Medicare Covers for Sleep Apnea Testing and Treatment

Medicare covers sleep apnea testing, but only under specific conditions

Medicare Part B covers an initial sleep apnea test if your doctor refers you and documents that you have symptoms — such as excessive daytime sleepiness, witnessed breathing pauses, or high blood pressure. The test itself (called a polysomnography or home sleep apnea test) is covered at 80 percent of the approved amount after you meet your Part B deductible. You pay the remaining 20 percent, plus any amount above Medicare's approved rate if your provider does not accept assignment.

The catch is that Medicare will not pay for a sleep study just because you think you might have sleep apnea. Your doctor must order it, and the order must be based on a clinical evaluation — not a screening questionnaire alone. If you go to a sleep lab without a doctor's order, Medicare will deny the claim.

Coverage for follow-up tests and treatment devices (such as a CPAP machine) follows different rules, which are covered in the sections below.

Key Takeaways

• Your doctor must order the sleep test and document symptoms or risk factors; Medicare will not cover a test ordered by the patient alone.
• An initial sleep apnea test is covered at 80 percent after your Part B deductible, whether done in a lab or at home.
• A CPAP machine or other treatment device is covered only if the sleep test confirms moderate to severe sleep apnea and your doctor prescribes it.
• Medicare covers replacement CPAP masks, tubing, and filters, but the rules for frequency and cost-sharing depend on whether you rent or own the machine.
• If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower, but coverage rules vary by plan.

How Medicare decides whether to cover your sleep test

Medicare uses a set of criteria called "coverage with evidence development" (CED) for sleep apnea testing. This means the test is covered, but only if certain conditions are met before the test happens, not after. Your doctor must document one or more of the following: excessive daytime sleepiness, unrefreshed sleep, witnessed apneas (someone saw you stop breathing), gasping awake, or nocturia (waking to urinate). High blood pressure alone is not enough.

The doctor's order must also specify which type of test: an in-lab polysomnography (PSG) or a home sleep apnea test (HSAT). Both are covered, but your doctor chooses based on your situation. Home tests are less expensive and more convenient, but not suitable for everyone — for example, if you have certain heart conditions or severe obesity, an in-lab test may be required.

If your doctor orders a test without documenting these symptoms, or if you arrange a test on your own, Medicare will likely deny the claim. You would then owe the full cost.

What happens after the test confirms sleep apnea

If your sleep test shows moderate to severe obstructive sleep apnea (an apnea-hypopnea index of 15 or higher), Medicare covers a CPAP machine, bilevel machine, or oral appliance prescribed by your doctor. The device itself is covered at 80 percent after your deductible, just like the test.

Medicare also covers the supplies that go with the machine: masks, tubing, filters, and humidifier cartridges. However, the cost-sharing and replacement schedule depend on whether you rent or own the device. If you rent through a durable medical equipment (DME) supplier, you typically pay 20 percent of the rental cost, and the supplier replaces worn parts at no extra charge. If you own the machine outright, you pay 20 percent of the purchase price, and you must buy replacement supplies separately — masks every three months, filters every six months, tubing as needed.

Mild sleep apnea (an index between 5 and 14) is not covered by Medicare, even with a doctor's prescription. Some Medicare Advantage plans cover mild sleep apnea, so check your plan documents if you fall into this category.

The difference between renting and buying a CPAP machine

Medicare allows you to rent a CPAP machine from a DME supplier for up to 13 months. During this time, you pay 20 percent of the monthly rental cost (after your deductible). After 13 months, the machine becomes yours, and you own it outright — but you then become responsible for buying all replacement supplies.

Alternatively, you can purchase the machine outright from the start. You pay 20 percent of the approved purchase price, and you own it when ready. This option makes sense if you know you will use the machine long-term and want to avoid the 13-month rental period. However, you must then budget for ongoing supply costs.

Some people rent for 13 months, then purchase a new machine when the rental ends, because the rental period covers the cost of trying the device and finding the right mask fit. Ask your DME supplier which option costs less in your situation — the math depends on local pricing and how long you plan to use the machine.

Out-of-pocket costs and how Medigap or Medicare Advantage changes them

Under Original Medicare (Part A and Part B), you pay your Part B deductible (currently $240 per year, though this amount changes annually) plus 20 percent of all approved charges for the test, machine, and supplies. There is no Part B out-of-pocket maximum, so your costs can add up if you need multiple tests or devices.

If you have a Medigap policy, the plan may cover your 20 percent coinsurance and deductible, depending on which Medigap plan you hold. Plans C, D, G, and M cover the Part B deductible; most Medigap plans cover the 20 percent coinsurance. Check your policy or call your Medigap insurer to confirm what sleep apnea testing and equipment are covered.

If you have a Medicare Advantage plan (Part C), coverage for sleep apnea testing and devices varies widely. Some plans cover the same services as Original Medicare; others cover mild sleep apnea or waive the deductible. A few plans do not cover CPAP machines at all. Review your plan's formulary and coverage documents, or call the plan directly, before scheduling a test.

Common reasons Medicare denies sleep apnea claims

The most frequent denial is a missing or incomplete doctor's order. If your doctor did not document symptoms before ordering the test, or if you scheduled the test yourself without a referral, Medicare will deny it. Always confirm with your doctor's office that they have submitted the order to the sleep lab and that it includes the required documentation.

A second common reason is that the test result shows mild sleep apnea (an index below 15). Medicare does not cover treatment for mild sleep apnea, even if you have symptoms. If this happens, ask your doctor whether a second opinion or a different test might change the result, or explore whether your Medicare Advantage plan covers mild cases.

A third reason is that you used an out-of-network provider or a provider who does not accept Medicare assignment. Always check that your sleep lab and DME supplier are Medicare-enrolled and accept assignment before you schedule. If they do not, you may owe more than the standard 20 percent coinsurance.

How to move forward: steps to take with your doctor

Start by scheduling an appointment with your primary care doctor or a sleep specialist. Bring a list of your symptoms — daytime sleepiness, snoring, witnessed apneas, or waking gasping. Your doctor will decide whether a sleep test is warranted and will place the order directly with a Medicare-enrolled sleep lab or DME supplier.

Ask your doctor's office to confirm that the order includes documentation of your symptoms and specifies whether an in-lab or home test is appropriate. Request the name and contact information of the sleep lab so you can verify they accept Medicare and accept assignment.

Once the test is scheduled, contact your Medicare plan (or Medigap insurer, if you have one) to ask what your out-of-pocket cost will be. This gives you time to budget and to ask whether any part of the cost can be waived or reduced. If the lab or supplier quotes you a price higher than Medicare's approved amount, ask whether they accept assignment — if they do, you should not owe more than 20 percent of the approved amount.

Frequently Asked Questions

Can I get a sleep test without a doctor's order?

No. Medicare requires a doctor's order based on a clinical evaluation. If you schedule a test on your own or through a direct-to-consumer service, Medicare will not cover it, and you will owe the full cost. Always start with your primary care doctor.

Does Medicare cover a second sleep test if the first one was normal?

Medicare generally covers only one initial sleep test. If your first test was normal and you still have symptoms, ask your doctor whether a second test is medically necessary — for example, if your symptoms have worsened or if the first test was inconclusive. Your doctor must document the reason, and Medicare will review it.

What if I have a CPAP machine from before I turned 65 and got Medicare?

Medicare will not cover a machine you already own. However, if your machine breaks or wears out, Medicare will cover a replacement if you have a current sleep test (within the past year) showing moderate to severe sleep apnea and a doctor's prescription. Bring your old machine and the test results to your DME supplier.

Does Medicare cover oral appliances or dental devices for sleep apnea?

Yes, if your sleep test confirms moderate to severe sleep apnea and your doctor prescribes an oral appliance instead of a CPAP machine. Medicare covers the device at 80 percent after your deductible. However, the dentist or orthodontist must be enrolled in Medicare and accept assignment, which is less common than with CPAP suppliers.

Will my Medicare Advantage plan cover sleep apnea testing?

Most Medicare Advantage plans cover sleep apnea testing and CPAP machines under the same rules as Original Medicare, but some cover mild sleep apnea or have lower deductibles. A few plans exclude CPAP coverage entirely. Check your plan's coverage documents or call the plan's customer service line before scheduling a test.