Does Medicare Cover Inspire for Sleep Apnea?

Medicare Part B covers the cost of Inspire for sleep apnea and other medical devices as long as a doctor determines them medically necessary for your care.

Original Medicare and Medicare Part C (Advantage) plans typically cover FDA-approved and medically necessary medical devices and procedures, including Inspire for obstructive sleep apnea.

You may need testing to confirm your diagnosis and show that the device is necessary and appropriate for your situation.

If you have a Medicare Advantage plan, you may need to check with your provider for specific details about coverage.

Keep reading to learn about Medicare coverage and eligibility for Inspire and other sleep apnea devices and your possible out-of-pocket costs.

What does Medicare cover for sleep apnea?

If you have obstructive sleep apnea, Original Medicare and Medicare Advantage plans cover medical devices, testing, and treatment your doctor deems medically necessary.

For treating sleep apnea, Medicare typically covers:

• medical appointments

• testing, such as sleep studies

• FDA-approved medical devices, including oral sleep apnea devices, such as positive airway pressure machines, sleep apnea surgery, and surgically implanted devices, such as Inspire

What is Inspire for sleep apnea?

Inspire is an implanted hypoglossal nerve stimulation device that treats obstructive sleep apnea by monitoring your breathing and delivering impulses to the nerve responsible for tongue movement. This keeps your tongue positioned in the front of the mouth to reduce obstruction during sleep. Implanting it in your chest requires a surgical procedure.

How does Medicare determine eligibility for sleep apnea devices like Inspire?

For Original Medicare to cover Inspire for obstructive sleep apnea, you must meet the indications outlined by Medicare:

• be age 22 or older

• body mass index (BMI) of less than 35

• polysomnography test results show an apnea-hypopnea index (AHI) of 15 to 65 events per hour

• diagnosis of obstructive sleep apnea, with central and mixed apneas less than 25% of the total AHI

• being unable to use or tolerate continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) machines, or these treatments were not effective

• confirmed absence of complete concentric collapse at the soft palate level by a drug-induced sleep endoscopy

• testing to show your anatomy, such as large tonsils, will not affect the device’s performance

A doctor may also test you for other conditions to be sure the device will be safe for you.

If you have a Medicare Advantage plan, you may need to check with your plan’s provider to determine if Inspire is covered.

If you have never tried a PAP or BiPAP device before, you may need to try one before a doctor will deem the Inspire medically necessary. For Medicare to cover a positive airway pressure device, your sleep test results must meet either of the following criteria:

• AHI greater than or equal to 15 events per hour with a minimum of 30 events, or

• AHI greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of either:

  • excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

  • high blood pressure (hypertension), ischemic heart disease, or a history of stroke

How much does the Inspire sleep apnea implant cost with Medicare?

Your out-of-pocket cost for the Inspire sleep apnea device can depend on where you have the surgery to implant it.

It is likely most cost-effective to have the procedure performed at a hospital outpatient surgery center that accepts the Medicare-approved procedure cost. The out-of-pocket cost for the Inspire sleep apnea implant may be:

• $1,796 at a hospital outpatient surgical center

• $5,133 at a non-hospital surgical center

You typically pay 20% of a Medicare-approved amount for a procedure. However, if you have the procedure in a hospital, it will likely be covered under Medicare Part A (hospital insurance). Part A has an out-of-pocket maximum of $1,632 per benefit period.

You may also have additional facility-specific fees.

If you have the procedure at a facility that does not accept the Medicare-approved cost, you may also be responsible for the difference between what Medicare covers and the facility charges. Before scheduling a procedure, consider asking if they accept the Medicare-approved cost.

The bottom line

Medicare typically covers FDA-approved devices and treatments if they are medically necessary for treating sleep apnea. This includes Inspire for obstructive sleep apnea.

You may have to have additional testing to show that a device is medically necessary.

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