Does Medicare cover CPAP machines? Coverage, compliance, and how to keep it

Short answer

Yes. Medicare Part B covers CPAP machines as durable medical equipment for obstructive sleep apnea when a Medicare-approved sleep study confirms the diagnosis and your doctor prescribes the device. You pay the 2026 Part B deductible of $283, then 20% of the Medicare-approved amount. The machine starts with a 12-week trial, followed by a 13-month capped rental that transfers ownership to you. Compliance monitoring is required during the trial.

Who qualifies: sleep study, AHI, and comorbidities

Medicare uses two clinical thresholds from national coverage policy to decide who qualifies for a CPAP machine, both measured by an Apnea-Hypopnea Index (AHI) from a Medicare-approved sleep study.

Threshold 1 — AHI of 15 or higher. If your sleep study shows 15 or more apnea or hypopnea events per hour, you qualify. No comorbidities required.

Threshold 2 — AHI of 5 to 14 with documented comorbidities or symptoms. If your AHI is between 5 and 14, you qualify if the medical record also documents at least one of: excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or a history of stroke.

The sleep study itself must be Medicare-approved. Two paths qualify:

• In-lab polysomnography — the traditional overnight sleep study at an accredited sleep lab. Comprehensive but often has waitlists.

• Home sleep apnea test (HSAT) — Medicare now covers Type II, III, and IV home tests. Much faster to schedule and less expensive. Medicare expanded home sleep testing coverage in recent years to reduce reliance on in-lab studies.

Both paths require a face-to-face evaluation by your doctor before the sleep study is ordered. Bring notes on symptoms: snoring, witnessed apneas, morning headaches, daytime fatigue, difficulty concentrating. Specifics matter more than general complaints. If you also have chronic pulmonary disease, tell your doctor — OSA and COPD often overlap, and the combination changes the diagnostic and treatment approach.

The 90-day compliance rule most patients don’t realize

The 12-week trial period is where the majority of CPAP coverage denials happen — and almost always for the same reason. Medicare requires you to use the CPAP at least 4 hours per night on at least 70% of nights during any 30 consecutive-day window within the first 90 days. The machine tracks your usage automatically and reports the data to your supplier and to Medicare.

If you meet the rule, Medicare continues to pay and the 13-month capped rental proceeds normally, converting to ownership after month 13.

If you fail the rule — even by a small margin — Medicare stops paying. The supplier will reclaim the machine. There is no refund of what you already paid, and you cannot simply resume where you left off. To restart, you generally need a new face-to-face evaluation, possibly a repeat sleep study, and to meet the qualifying criteria again from scratch.

Most compliance failures are avoidable and come from three patterns:

• Mask problems: an uncomfortable mask leads to short nights. Ask your supplier to try different mask styles (nasal, nasal pillow, full-face) early rather than pushing through discomfort.

• Pressure problems: initial pressure settings often need adjustment. If you cannot tolerate the prescribed pressure, ask about auto-titrating (APAP) or a pressure-relief feature.

• Not tracking usage: many patients don’t check the built-in usage counter until day 89. Ask the supplier to walk you through reading the display or the app on day one.

Failing compliance is not personal fault — it’s a documentation and equipment-fit problem. Addressing it early is the difference between a 12-week trial and a lost benefit.

What Medicare pays vs. what you pay

CPAP machines fall under Medicare Part B, which uses an 80/20 cost split after the annual deductible.

• Part B deductible (2026): $283 for the year, paid once regardless of how many DME items you use.

• Coinsurance (2026): 20% of the Medicare-approved amount each rental month. Medicare pays the other 80%.

• Medigap: Plans G and F typically pay the 20% coinsurance in full. Plan G is the most common newer purchase; Plan F is available only to those eligible for Medicare before January 1, 2020.

• Medicare Advantage plans: Cost-sharing varies by plan. Most plans must offer at least what Original Medicare covers, but may have different prior-authorization rules and supplier networks.

Typical out-of-pocket during the 13-month rental (approximate, before Medigap):

• CPAP machine: $160 to $240 total over the rental period after the deductible is met.

• Supplies: $60 to $80 per month while you are using the machine, depending on which items need replacing that month.

With Medigap Plan G or F, most clients pay $0 out of pocket for the machine and supplies once the deductible is met.

CPAP supplies replacement schedule

Medicare pays for CPAP supplies on a set schedule. Order them at the right frequency and Medicare covers them. Order too early or skip them and Medicare will not pay.

Most Medicare-enrolled CPAP suppliers offer an auto-shipment program that matches this schedule. Ask when you receive the machine. If you decline auto-shipment, keep a calendar reminder — running out of filters or a broken mask cushion is one of the top reasons clients briefly stop using their machine, which then puts compliance at risk.

Beyond CPAP: APAP, BiPAP, and ASV

CPAP delivers a single continuous pressure. Some clients need different equipment to breathe comfortably through the night. Medicare covers three step-up options when the medical record documents that standard CPAP is not working.

Escalating from CPAP to BiPAP or ASV requires new documentation: usage data showing CPAP was tried, clinical notes explaining why CPAP is inadequate, and a new prescription. The 12-week trial and compliance rule apply again to the new device.

How to get a Medicare-covered CPAP: step by step

Six steps. Most delays and denials happen because a step gets skipped or paperwork is missing.

Step 1 — Face-to-face evaluation with your doctor. Tell your doctor about the symptoms — snoring, daytime fatigue, witnessed apneas, headaches. Ask for a sleep study referral. The doctor’s note has to document why the study is medically necessary.

Step 2 — Sleep study. Either in-lab polysomnography or a Medicare-approved home sleep apnea test. Wait for the report. The report must include the AHI number and, if AHI is between 5 and 14, documentation of qualifying comorbidities or symptoms.

Step 3 — Diagnosis and prescription. After the sleep study, your doctor formalizes the OSA diagnosis and writes a prescription for CPAP. Medicare calls this the Written Order Prior to Delivery, or WOPD. It must include your name, the CPAP device, pressure settings, the date, the treating clinician’s signature, and the medical reason.

Step 4 — Choose a Medicare-enrolled DME supplier. Only accredited, Medicare-enrolled suppliers can bill Medicare for a CPAP. Use the directory at medicare.gov/care-compare, filtering by durable medical equipment. Ask two questions before you commit: “Do you accept assignment?” (locks in the Medicare-approved amount as the price) and “Do you support the 12-week trial with usage monitoring?” (some suppliers do this better than others).

Step 5 — Machine delivery and setup. The supplier delivers, fits the mask, sets the prescribed pressure, and shows you how to operate the machine. Ask specifically how to check your usage — this is what determines whether you pass compliance.

Step 6 — The 12-week trial begins. Compliance monitoring runs continuously through days 1 to 90. If you meet the 4-hour/70% rule during any 30-day window, coverage continues into the 13-month capped rental. After 13 months of continuous rental, ownership transfers to you.

Replacement: how often Medicare pays for a new CPAP

Once you own the machine, Medicare will generally pay for a replacement only after five years — Medicare’s reasonable useful lifetime for CPAP machines. Exceptions:

• Lost, stolen, or damaged beyond repair in circumstances outside your control (fire, flood, theft with a police report): Medicare may cover an earlier replacement with documentation.

• Medical condition change requiring different equipment (for example, escalation from CPAP to BiPAP): Medicare may cover the new device before the 5-year mark with a new sleep study and prescription.

• Repairs: while you own the machine, Medicare covers reasonable and necessary repairs under the same 80/20 cost split.

For each replacement, Medicare requires documentation that you still have OSA and are still using the therapy — the same clinical criteria that qualified you the first time.

What if Medicare denies your CPAP claim (or reclaims your device)?

Denials happen most often for four reasons: the sleep study documentation did not meet CMS criteria, the face-to-face evaluation was missing or incomplete, the supplier was not enrolled or accredited, or the compliance rule was not met during the 12-week trial.

If you receive a denial or a reclamation notice:

1. Read the notice carefully. Look for the specific reason code and what documentation Medicare wants.

2. Ask your doctor to add to the record. Most denials are fixable by adding the missing clinical language to the chart and resubmitting.

3. File a redetermination within 120 days. You have 120 days from the date on the Medicare Summary Notice to file the first-level appeal. Include additional documentation and the odds of reversal are meaningful.

4. For compliance failures specifically, the reclamation itself may not be appealable, but you can restart the qualification process. In some cases, if you can document that the failure was caused by a mask fit or pressure issue that has since been resolved, an appeal is possible.

5. Get help. Free help is available from your State Health Insurance Assistance Program (SHIP) at shiphelp.org, and the Medicare Rights Center at 1-800-333-4114. For end-to-end handling, that is what a patient advocate does.

For a full walkthrough of the appeal process, see How to appeal a Medicare denial.

How Baba helps

Most CPAP coverage failures happen for reasons that are preventable if someone is watching the timeline. Baba advocates work the CPAP journey from before the sleep study through the end of the 12-week trial: they help schedule the Medicare-approved sleep study (in-lab or home), coordinate the face-to-face documentation with your doctor’s office, verify the supplier’s Medicare enrollment and accreditation, and — most importantly — set compliance-check reminders at days 30, 60, and 85 to catch a usage shortfall before it becomes a coverage loss.

If you are already past a denial or a compliance-based reclamation, Baba prepares and files the redetermination on your behalf, coordinates the mask-fit or pressure issue documentation with your doctor’s office, and if a restart is needed, manages the full re-qualification. Medicare may cover qualifying care navigation or advocacy services, so some clients pay little or nothing out of pocket. Talk to Baba to find out if you qualify.