Insurance Coverage for CPAP, Bi-PAP, and PAP Therapy

This SleepSomatics blog article is part three of a six part series on CPAP Therapy, Bi-PAP (or Bi-Level) Therapy, and Treating Sleep-Disordered Breathing (Sleep Apnea) with Non-Invasive PAP Therapy.

Part One: Drowsy Driving Kills

Part Two: What are CPAP, Bi-PAP, and PAP Therapy

Part Three: Insurance Coverage for CPAP, Bi-PAP, and PAP Therapy

Part Four: PAP Masks: Keep it Simple, Small, and Silent

Part Five: Side-Effects and What to Expect from CPAP, Bi-PAP, and PAP Therapy

Part Six: Cleaning and Servicing your CPAP, Bi-PAP, and PAP Therapy

When a sleep apnea patient is referred to SleepSomatics for accredited sleep testing, one of the first questions asked is whether insurance covers sleep apnea treatment with CPAP Therapy. The short answer is yes, most private insurances and Medicare/Tricare provide benefits coverage for sleep apnea treatment. If you are a sleep apnea patient, call SleepSomatics for review of your insurance coverage.

This article focuses on one important aspect of insurance CPAP coverage. Most insurances now require certification of Compliance to maintain benefits coverage of sleep apnea treatment with CPAP or Bi-PAP (Bi-Level) Therapy.

What is PAP Therapy Compliance?

CPAP Compliance is a calculation of the average amount of time spent nightly using CPAP over a specific usage period (generally, 30 days).

The "Medicare Standard" for CPAP Compliance is 4 or more hours nightly usage on 70% or more of sampled nights, or 21 of 30 days. By comparison, the American Academy of Sleep Medicine recommends 7 or more hours nightly usage. With sleep apnea, treatment is only effective when using CPAP. So if a patient sleeps 4 hours with his or her therapy, takes the mask off at hour four, and resumes sleeping for 3 more hours, the effectiveness of treatment is limited. Sleep apnea returns as soon as you fall asleep without your mask. That is why SleepSomatics recommends that all patients use their CPAP whenever sleeping, napping, or traveling.

CPAP Compliance usage is recorded on most CPAP devices. The data recorded by the CPAP machine can vary from manufacturer to manufacturer, but at a minimum, time spent using therapy nightly and what, if any, sleep apnea or snoring occurred at the prescribed pressure are all recorded. This data, often called a 'CPAP Download,' can be accessed by an accredited sleep center like SleepSomatics and reviewed by a sleep medicine specialist or physician.

Many private insurances now follow the same standard as Medicare for reimbursement determination. A patient may be initially authorized for treatment and receive a CPAP machine. After 30-90 days has passed, it is determined that the patient's compliance is below the minimum 4 or more hours nightly on 70% or more of nights during usage period. In some cases, coverage may be terminated and equipment returned (or not reimbursed).

Why CPAP Compliance Affects Sleep Apnea Patients

This Compliance standard is important for patients to understand if they are unmotivated to use PAP Therapy to treat their sleep apnea. At SleepSomatics, we counsel our patients to seek second opinions for alternative approved treatments (such as a surgical consultation with an otolaryngologist) if they are not committed to PAP Therapy. Our focus is on our patients getting their sleep apnea and snoring treated with whatever treatment option best works for the patient and their lifestyle.

CPAP Therapy is an effective, non-invasive treatment option, and with an in-lab sleep study, SleepSomatics can quantify precisely how effective CPAP is in improving your sleep quality, sleep continuity, and restorative sleep.

To improve CPAP Compliance and support sleep apnea patients in effective, comfortable treatment, SleepSomatics utilizes simple, small, silent CPAP masks as small as 1.94 ounces! But if a patient still remains unmotivated, then we often recommend patients consider non-CPAP treatment options because of the Compliance standards most insurances now require.

CPAP Compliance and Commercial Driver's Licenses (CDL)

CPAP Compliance Standards are also increasingly used by Medical Examiners for Department of Transportation (DoT) Commercial Driver's License (CDL) physicals. With increasing news reports of fatal truck accidents caused by sleepiness or untreated sleep apnea, the Federal Motor Carrier Safety Administration recognizes the danger of commercial and truck drivers with untreated sleep apnea. Sleep apnea patients with CDL or similar workplace certifications may also have to demonstrate CPAP Compliance standards, as well.

If you have sleep apnea, identifying the correct treatment begins with accredited sleep testing at SleepSomatics. If CPAP or Bi-PAP (Bi-Level) Therapy is recommended, our sleep clinicians excel at supporting your initial PAP acclimation period. Getting a better night's sleep starts with a single phone call to SleepSomatics. Our excellent patient reviews attest to the sleep treatment services provided at SleepSomatics.

Concerned you aren't getting enough sleep? If you or someone you care about snores or is tired and fatigued during the day, sleep-disordered breathing (and sleep apnea) may be a serious risk. Get your sleep tested today by SleepSomatics, a professionally credentialed and accredited sleep test center located in Austin since 1999. Call 512.323.9253.

For more information on CPAP Therapy Compliance and CDL Requirements for patients being treated for sleep apnea and snoring, read this SleepSomatics article's sources:

All That's Trucking: "Do Drivers With Sleep Apnea Have to Use a CPAP Machine?"

Bloomberg Business: "Trucker in Massive Rig Destroys Two Families in His Sleep"

Business Examiner: "Tighter medical regulations adding to driver shortage"

Centers for Medicare & Medicaid Services: "National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea"

Department of Health and Human Services, Centers for Medicare and Medicaid Services: Continuous and Bi-Level Positiv Airway Pressure (CPAP/BPAP) Devices: Complying with Documentation & Coverage Requirements

Overdrive: " Driver sleep apnea screening: FMCSA to issue clarification to medical examiners"

Overdrive: "NTSB asks trucking regulators to require sleep apnea screening, collision mitigation tech"

This blog article's thumbnail image credit goes to: Michigan Auto Law " Why trucking companies must aggressively screen truck drivers for sleep apnea"


SleepSomatics Diagnostic Center is a credentialed and accredited sleep center serving Austin and Central Texas since 1999. We provide sleep diagnostic and therapy services including In-Lab Sleep Study, Take-Home Sleep Test, and Sleep Therapy. We gladly accept most insurances and provide you with a written quote of any costs. Questions? Get answers. Let's talk. Call us. We're ready when you are. Call SleepSomatics at (512) 323-9253.