Medicare may cover Inspire, a device to treat sleep apnea, if it is medically necessary. A doctor needs to demonstrate that people meet certain criteria and CPAP therapy has been ineffective.
Inspire is a hypoglossal nerve stimulator (HNS) to treat obstructive sleep apnea. It is an implantable device that stimulates nerves controlling the tongue. The device causes the tongue to move forward in the mouth, opening the airways during sleep.
Medicare may cover Inspire if it is medically necessary to treat sleep apnea. This article looks at when Medicare may cover Inspire, potential costs, and whether Medicare covers other sleep apnea treatments.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare plans may cover Inspire if it is medically necessary to treat moderate to severe sleep apnea. People will need to meet all of the following criteria:
- is 22 years or older
- has a body mass index (BMI) below 35
- a sleep study shows they have moderate to severe sleep apnea within 24 months of the first consultation
- they have mostly obstructive sleep apnea events
- continuous positive airway pressure (CPAP) therapy has been ineffective or a person cannot tolerate it
- they do not have complete concentric collapse, which means the soft palate and sides of the throat fully block the airways
- there are no anatomical factors that would affect how Inspire works
Coverage for Inspire may vary with different Medicare plans:
- Original Medicare: Original Medicare will typically cover 80% of Medicare-approved costs of the treatment. After meeting the Part B deductible, people may pay 20% of the Medicare-approved cost.
- Medicare Advantage, or Part C: Medicare Advantage coverage may vary with different insurance providers and plans. If people have Medicare Advantage, they can check with their insurance provider for any out-of-pocket costs for Inspire.
Whether a person requires medical treatment for sleep apnea depends on the condition’s severity. For mild sleep apnea, a person can make changes to their lifestyle,
- taking part in regular physical activity
- maintaining a moderate BMI
- limiting caffeine or alcohol intake
- maintaining healthy sleeping habits
- quitting smoking, if applicable
A person may also benefit from sleeping on their side instead of their back to open the airways.
A doctor will be able to advise on whether a person requires a breathing or oral device, such as a CPAP machine, or other treatment options such as Inspire.
Inspire treatment for sleep apnea may be medically necessary if a person meets all of the Centers for Medicare & Medicaid Services (CMS) set criteria.
The costs of Inspire may depend on the facility where people have the procedure done. According to 2024 figures, the national average cost of an Inspire procedure may be as follows:
| Location | Total cost | Medicare pays | Patient pays |
|---|---|---|---|
| ambulatory surgical center | $25,669 | $20,535 | $5,133 |
| hospital outpatient department | $30,408 | $28,612 | $1,796 |
Original Medicare caps copayments at $1,632 in hospital outpatient departments, which may apply with the Inspire procedure.
Costs may vary depending on whether a person has a Medicare Advantage or Medigap plan and the coverage of the plans.
These figures derive from Medicare’s 2024 payments and copayments.
Original Medicare Part B covers sleep test types 1 to 4. It also covers devices for people who have clinical signs and symptoms of sleep apnea.
If people receive a diagnosis of obstructive sleep apnea, Medicare may cover a 3-month trial period of a CPAP therapy device. If a doctor then documents that CPAP is helping, Medicare may continue to provide coverage.
With Original Medicare, once people meet their Part B deductible, they will pay 20% of the Medicare-approved costs for sleep apnea treatments.
Without proper diagnosis and treatment, sleep apnea can
Sleep apnea can increase the risk of serious health conditions,
People need to contact a doctor if they have any symptoms of sleep apnea, such as:
- breathing that repeatedly stops and starts during sleep
- frequent, loud snoring
- gasping for air or choking during sleep
- daytime sleepiness
People can talk with a doctor about treatment options and potential costs. Before starting sleep apnea treatment, individuals can check with a provider what costs Medicare will cover and what out-of-pocket costs people will pay.
Medicare may cover Inspire if people meet certain criteria that deem treatment medically necessary. These include factors such as age, other health conditions, and sleep study results.
A doctor must show that people meet certain conditions and have tried continuous positive airway pressure (CPAP) therapy, but it has been ineffective.