Medicare covers Inspire, an implanted device that treats sleep apnea, if it’s medically necessary. Sleep apnea is a condition that causes you to repeatedly stop and restart breathing while you sleep.
Inspire is an alternative to CPAP machines. A continuous positive airway pressure (CPAP) machine is a common treatment for sleep apnea. Medicare covers CPAP machines and supplies through a trial process to confirm that it works well for you.
If a CPAP machine hasn’t worked well for you, Inspire could be another option.
What’s required to get coverage for Inspire
For Medicare to cover Inspire, you need to meet specific medical criteria.
Some criteria have to do with your general medical condition. For example, you generally need to be at least 22 years old and under a certain body mass index number. And you can’t have medical or anatomical issues in areas of your mouth and throat that would prevent Inspire from working as intended.
Other criteria have to do with your sleep apnea. You need to have a polysomnography, or a sleep study, that shows that you meet the standards for moderate or severe obstructive sleep apnea.
Finally, you have to be able to demonstrate that a CPAP machine hasn’t worked for you, despite working with a sleep expert.
If you and your doctor can demonstrate that you meet all of the criteria, Inspire is considered medically necessary, so Medicare will cover it.
Does Medicare Advantage cover Inspire?
Medicare Advantage plans, also known as Medicare Part C, must cover at least the same benefits as Medicare Part A and Part B. So your Medicare Advantage plan would cover Inspire if it’s medically necessary.
Medicare Advantage plans have their own rules for referrals, prior authorization and provider networks. Check with your plan to find out the specifics of how Inspire would be covered.
Medicare Advantage companies
Get more information below about some of the major Medicare Advantage companies. These insurance companies offer plans in most states. The plans you can choose from will depend on your ZIP code and county.
What you pay for Inspire
Inspire is implanted through an outpatient surgery that falls under Medicare Part B.
If you have Medicare Part B, it generally pays 80% of the total allowed cost for covered procedures after you meet the annual deductible of $226 in 2023. You would be responsible for the other 20%.
Costs for the surgery depend in part on where it takes place. Here are average patient costs for Inspire for people with Medicare Part B, according to Medicare.gov:
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At a hospital outpatient department: $1,733.
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At an ambulatory surgical center: $5,142.
Medicare Advantage companies set their own requirements for out-of-pocket costs such as copays, coinsurance and deductibles. If you have Medicare Advantage, check with your plan to see what your costs would be.
What Medicare covers
Medicare covers a lot of things — but not everything. Find out where Medicare stands in the following areas:
Alex Rosenberg
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