Many new CPAP users are surprised to learn that how often you use your machine can affect whether insurance keeps paying for it. The rules are manageable once you know them, and we monitor your usage and help you stay on track. Here is a plain-English guide. Your own plan may differ, so we will always check your specific coverage.

How getting started works

For most new CPAP patients, we handle the paperwork before you ever come in, so your setup visit can be about you, not forms.

  1. Your doctor orders your CPAP. After your sleep study and diagnosis, your doctor’s office sends us your order, your sleep study results, and your visit notes.
  2. We get everything in order. We review your documentation, set up your information from your photo ID and insurance cards, and verify your coverage. If anything is missing, we follow up with your doctor’s office ourselves. We only involve you if we are not getting a response.
  3. We call you to schedule your setup. Once everything is in place, we contact you for an appointment with one of our PAP specialists. It helps to make sure your doctor’s office has your correct phone number.
  4. Setup visit. We install and set up your machine, show you how it works, and teach you how to care for and clean it.

There is very little to bring. We already have your insurance information and have verified your coverage. If you already have a machine and are not yet due for a new mask, bring the mask you are using now.

Already have a prescription in hand? Call or stop by and we can start the process. But CPAP needs more than a prescription. We also need your sleep study and your doctor’s notes, so it usually goes fastest when your doctor’s office sends everything straight to us.

The first 90 days: your compliance period

Your CPAP is provided as a rental, and your insurance company requires you to meet compliance guidelines to keep coverage. You have 90 days to meet them.

  • Usage: at least 4 hours a night on at least 70% of nights during a consecutive 30-day period, at any point in your first three months of use. That works out to about 21 nights out of 30.
  • Doctor re-evaluation: no sooner than day 31 and no later than day 91 after you start therapy, your doctor must see you in person, document that your sleep apnea symptoms are improving, and review objective evidence that you are using the machine.
  • Other insurers: many private plans follow similar rules, but not all. Ask us and we will check.

How your usage is tracked

Every machine we provide has a cellular connection built in, so your usage is sent to us automatically. There is nothing to download or mail in. It works well almost everywhere. In some rural areas, or in homes with a metal roof, the signal can be weak. If that happens, let us know and we will work around it.

What you need to do

  • Use your machine every night, and for naps.
  • Call us when your re-evaluation appointment is scheduled. We will make sure a usage report from your machine is sent to your doctor before the visit.
  • Tell us about any difficulty right away, so we can work with you during your compliance period.

If the guidelines are not met, insurance coverage will be denied and the machine must be returned to us. We would much rather help you fix a problem in week two than find out about it on day 85.

Four hours is the minimum, not the goal

The 4-hour mark is just the bar for coverage. Sleep doctors generally want you using CPAP all night, every night, including naps. If you are only wearing it part of the night, that is a sign something needs fixing, such as fit, comfort, or pressure. It is not a sign you should give up. See our guides on the first week of CPAP and on mask noise, leaks, and discomfort.

Getting new supplies

Masks, cushions, headgear, tubing, filters, and humidifier chambers all wear out, and fresh parts keep your therapy comfortable and effective. Insurance generally allows replacements on a schedule, and the schedule differs by item and by plan.

  • Our supply replacement guide is on the FAQ page. It is a general guideline, and your insurance carrier may have slightly different requirements.
  • Masks: in practice, we tell patients they can get an entire new mask about every six months, and cushions, the soft part that touches your face, more often. Ask us for your exact schedule.
  • Order when you are eligible. Replacements generally cannot be shipped before your plan’s schedule allows, so ordering on time keeps your equipment fresh.
  • If something fails early, tell us. A broken part is different from routine wear.
  • The machine itself is generally replaced about every five years under Medicare’s schedule and most private insurances follow suit.

Questions? Ask us.

Call 800-442-6704 and we will schedule time with a PAP specialist at our La Grange or Bastrop office. They can walk you through your coverage and your supply schedule. You can also read more in our Medicare Resource Center.

This article is general information, not medical or legal advice. Coverage depends on your specific plan and policy.