If Medicare covers the cost of your CPAP equipment, you should know that they will want to make sure that you are using the equipment. Medicare refers to this as "compliance." Compliance is the measurement of how much you use your CPAP equipment and if it is working for you.
As far as Medicare is concerned, you are not compliant unless you are using your machine at least 4 hours each night for 70% of the nights. So, if you use your machine 22 days out of 30 for at least 4 hours a night you are compliant. If you use your machine for 3 hours, 59 minutes, and 59 seconds, you did not use it enough so you were noncompliant.
When documentation begins
Medicare considers the first 90 days a trial period. Documentation of compliance begins after 31 days of usage but before 90 days of usage. In other words, documentation must be done between Day 32 and Day 89 of the time you started using the machine.
How documentation is done
Patients must have a download of the CPAP usage from their machine and a face-to-face meeting with their sleep medicine physician who also documents other information, as noted below.
Medicare guidelines for CPAP
New patients
Patients must have a face-to-face evaluation with a physician of their choice and obtain:
- Documentation of obstructive sleep apnea (OSA) symptoms through a baseline sleep study
- Completed Epworth Sleepiness Scale
- BMI (body mass index)
- Neck circumference and
- Focused cardiopulmonary and upper airway system evaluation.
Note: The appointment with the physician must always come before the baseline sleep study.
Patients currently using CPAP who become Medicare patients
Patients must:
- Complete a baseline sleep study that meets Medicare criteria - It does not matter now long ago this baseline was performed.
Physicians must:
- Document that the patient's symptoms have improved with CPAP treatment.
Patients who do not have enough OSA
- The patient must follow the "New Patients" steps, above, and try to re-qualify for CPAP.
- If the prior baseline met Medicare criteria, the first face-to-face with the physician after going on Medicare must include documentation about the patient's CPAP compliance according to Medicare guidelines.
CPAP compliance not met
After 3 months, if a patient did not prove nightly usage of CPAP, Medicare will not cover the cost. If the patient wants Medicare to cover CPAP again, they must start with a new face-to-face evaluation with a physician and follow the "New Patients" steps, above.