Does Medicare Cover Inspire for Sleep Apnea?

Original Medicare covers Inspire for treating obstructive sleep apnea (OSA). However, certain conditions must be met before Medicare will cover the cost of the device.

Usually, Medicare Part B will cover the cost of an Inspire device as durable medical equipment, but only if the patient has been diagnosed with moderate to severe OSA and has tried other treatments without success, such as using a CPAP machine or oral appliance therapy.

Before any coverage can be provided, a physician must prescribe the device and provide documentation that the patient meets the specific criteria.

What’s Required to Get Coverage for Inspire?

To be eligible for coverage of Inspire under Medicare, beneficiaries should ensure that they have fulfilled the following criteria:

• They have been diagnosed with moderate or severe sleep apnea and have tried other treatments, such as a CPAP machine or oral appliance therapy, without success.
• Medicare has approved the procedure before it’s performed. Medicare has a pre-authorization process that confirms the procedure is medically necessary for the patient and meets Medicare’s criteria.
• In some cases (depending on the individual’s specific situation), the patient must also obtain an order from a physician stating that the Inspire therapy device is medically necessary to treat their sleep apnea.

After approval, the surgery to implant the device and the cost of the device itself are covered under Medicare Part B.

Out of Pocket Costs

Medicare covers 80% of the cost of the Inspire device and the implantation surgery after the Part B annual deductible is met. You will be responsible for the remaining 20% coinsurance, with no out-of-pocket limit.

Your out-of-pocket expenses and limits can be significantly reduced if you have additional coverage, such as a Medigap or Medicare Advantage plan. It is advisable to consult your insurance provider for a better understanding of your coverage.

Bottom Line

In conclusion, Medicare does cover the cost of Inspire for the treatment of obstructive sleep apnea, but specific criteria must be met, and a pre-authorization process is required.

Beneficiaries need to speak with their physician and insurance provider to ensure that they meet the specific criteria for coverage and to understand any additional costs not covered by Medicare.

Inspire is a promising treatment for sleep apnea and may be an option for individuals who have exhausted other therapies without success. It is essential to prioritize your health and well-being and work with your healthcare team to find the best treatment options.

Sources: Medicare.gov – National Council on Aging – CMS.gov – InspireSleep.com

FAQs

• What are the drawbacks of Inspire?

  There are some potential drawbacks to consider when considering the Inspire device. These include the risks associated with any surgical procedure, such as infection or bleeding. Additionally, because the device is implanted inside the body, it must be monitored and replaced every five years.

• How does Inspire work?

  Inspire is a small device implanted in the chest area under the skin. It works by stimulating the hypoglossal nerves, which control the tongue muscles. This stimulation keeps airways open during sleep, allowing for improved breathing and more restful sleep. The device also contains sensors that monitor your breathing patterns to ensure optimal therapy.