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How Does Insurance Decide Whether to Approve Your CPAP Machine?

June 29, 2021


Obstructive sleep apnea can lead to snoring, gasping, and even choking in some cases. For the more than 18 million people nationwide who suffer from sleep apnea, CPAP machines are often the best solution to their sleep issues. Most doctors encourage patients to wear their CPAP machine every night for best results. However, while the treatment is highly effective, it can also be expensive.

Luckily, most insurance plans at least partially cover the costs of CPAP machines and related equipment. Each program has slightly different requirements and guidelines for eligibility. We’ll go over some of the most common policies to help you understand how insurance decides whether to approve your CPAP machine.

Deductibles and Apnea-Hypopnea Index (AHI)

Typically, insurance providers require you to meet an annual deductible before covering the costs of CPAP equipment. Unfortunately, this means that patients with a high deductible may end up paying full price for their CPAP machine. Insurance providers may also consider your apnea-hypopnea index (AHI) when determining your eligibility for coverage. Your AHI is the average number of partial or complete lapses in breathing you experience per hour. It is determined during a sleep study or at home, using at-home testing equipment.

Sleep apnea is classified under three categories, based on the AHI reading: mild, moderate, and severe. An AHI from 5 to 15 is mild, an AHI from 15 to 30 is moderate, and an AHI greater than 30 is severe. Contact your insurance provider to learn more about your specific policy details and AHI requirements.

Insurance Compliance and Prescription Requirements

Sleep apnea patients often need to fulfill two major requirements before an insurance provider pays for their CPAP equipment. First, you need a prescription for CPAP therapy from a healthcare provider. After making an appointment with the doctor, they will check for common symptoms of obstructive sleep apnea, including:

  • Abrupt awakenings accompanied by gasping or choking
  • Observed episodes of stopped breathing during sleep
  • Excessive daytime sleepiness
  • Gasping or snorting
  • Nighttime sweating
  • High blood pressure
  • Loud snoring
  • Headaches

You may also be asked to complete a sleep study or “polysomnography” so that your doctor can make a final diagnosis. The second major requirement for CPAP coverage is to complete a compliance period with your CPAP machine. Essentially, you’ll need to demonstrate that you are using the treatment regularly. The Centers for Medicaid and Medicare (CMS) requires proof that you are using your machine at least 4 hours per night, 70% of nights, in a consecutive 30-day period. However, this varies for patients with private insurance plans. 

While these are the most common eligibility and compliance requirements for CPAP coverage, each insurance policy is slightly different and has its own rules. At Advanced Homecare, we understand the importance of having affordable CPAP treatment. Contact us today to learn how we can help you sleep better at night.

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