How To Get Medicare Coverage for BiPAP Machines

Yes, Medicare Part B does cover BiPAP machines, but the rules are stricter than many patients expect. BiPAP coverage is only approved after a therapeutic trial of CPAP therapy has been attempted and found either ineffective or intolerable. This matters because BiPAP—short for bilevel positive airway pressure—delivers more advanced respiratory support than CPAP and costs significantly more.

About 30 million Americans live with sleep apnea, but only 10–15% ultimately require BiPAP therapy. Those who do often fall into one of three groups:

• Patients who cannot tolerate the continuous pressure of CPAP
• Individuals with central or complex sleep apnea
• People with additional respiratory conditions like COPD or neuromuscular disorders

For them, BiPAP can be the difference between abandoning treatment and finally achieving relief.

Financially, the stakes are high. BiPAP machines cost between $1,200 and $3,000, while Medicare covers 80% after the deductible. But approval is not automatic. Beneficiaries must meet eligibility and documentation requirements, follow coverage indications, and work with their treating practitioner to provide the medical records Medicare requires.

This article explains how BiPAP differs from CPAP, outlines Medicare’s strict classification and coverage criteria, and walks through the step-by-step process for gaining approval, maintaining compliance, and managing costs.

Understanding BiPAP vs. CPAP and Medicare's Classification

When evaluating Medicare coverage for positive airway pressure (PAP) therapy, it’s important to understand how BiPAP differs from CPAP. Both devices fall under the durable medical equipment benefit, but Medicare treats them differently because of their complexity and cost.

What Makes BiPAP Different from CPAP

BiPAP machines deliver two pressure levels: higher for inhalation (IPAP) and lower for exhalation (EPAP). This dual-pressure setup makes breathing feel more natural for patients who struggle to exhale against CPAP’s fixed pressure.

By contrast, CPAP delivers one continuous pressure. While effective for most people with obstructive sleep apnea, CPAP can become difficult at high pressure settings. That’s when BiPAP is considered—especially for pressure-sensitive patients or those with more complex conditions.

From a Medicare standpoint, BiPAP is officially classified as a “bi-level respiratory assist device without backup rate” (HCPCS code E0470). Devices with a backup rate (E0471) are not covered for obstructive sleep apnea as the primary diagnosis.

• CPAP = first-line therapy under Medicare
• BiPAP = step-up therapy only if CPAP fails
• BiPAP = 2–3 times more expensive than CPAP, requiring stricter approval

Because of this cost gap, Medicare applies more rigid rules before authorizing BiPAP coverage.

When BiPAP Becomes Medically Necessary

BiPAP therapy becomes necessary when CPAP fails or is clinically inappropriate. This can happen for several reasons:

• Patients cannot tolerate CPAP due to discomfort or pressure intolerance
• Individuals have complex or central sleep apnea that CPAP cannot correct
• Patients have other respiratory disorders, such as COPD or neuromuscular disease

To qualify, Medicare requires a sleep study, clinical notes from the treating practitioner, and a documented face-to-face meeting. Continued symptoms like excessive daytime sleepiness or disrupted sleep must be recorded even after optimized CPAP use.

These eligibility and documentation requirements form the foundation of Medicare’s local coverage determination (LCD) for PAP devices. Without this supporting evidence, BiPAP claims are usually denied.

Medicare Eligibility Requirements for BiPAP Coverage

Medicare does not immediately cover BiPAP therapy. Patients must first meet strict eligibility and documentation requirements. These requirements are defined in local coverage determinations (LCDs) published by Medicare Administrative Contractors (MACs). To qualify, beneficiaries must undergo a sleep study, complete a CPAP trial, and show documented evidence of failure before BiPAP can be prescribed.

Initial Sleep Apnea Diagnosis Requirements

The first step toward BiPAP coverage is a qualifying sleep study. Medicare requires either an in-lab polysomnography (PSG) or an approved home sleep apnea test (HSAT), performed by a facility/entity that qualifies as a Medicare provider of sleep tests and meets applicable state requirements.

Results must meet one of the following clinical criteria, and documentation requirements also apply:

• An Apnea-Hypopnea Index (AHI) of 15 or greater
• An AHI between 5 and 14 with symptoms such as daytime sleepiness, insomnia, mood changes, or cardiovascular conditions
• Evaluation and documentation performed by a treating practitioner

A face-to-face evaluation before the study, and a diagnosis code in the medical record, form the basis for prescribing PAP therapy.

CPAP Trial and Failure Documentation

Medicare requires a documented trial of CPAP therapy before BiPAP approval. This trial may occur at home or in a facility, but it must reflect genuine effort to use CPAP.

Documentation must include:

• Optimized CPAP pressure settings and attempts with multiple mask types
• Compliance tracking with CPAP usage downloads
• Notes on unresolved symptoms, pressure intolerance, or side effects

If CPAP is unsuccessful, the treating practitioner must record these issues in the medical record during a face-to-face meeting within the three-month trial. This documentation demonstrates adherence to PAP therapy and establishes medical necessity for BiPAP.

BiPAP-Specific Approval Criteria

To move from CPAP to BiPAP, Medicare requires clear evidence of medical necessity. The medical record must include the original sleep study, CPAP trial notes, compliance data, and physician assessment.

Orders must come from a qualified treating practitioner or sleep medicine physician, and claims must include the correct HCPCS procedure codes with the KX modifier, certifying that coverage indications, limitations, and medical necessity requirements were met under the applicable LCD.

Here’s a quick reference for key codes and modifiers:

This coding and modifier documentation is mandatory for successful BiPAP approval.

BiPAP Trial Period and Compliance Monitoring

After Medicare approves BiPAP therapy, patients enter a structured three-month trial period. This stage is meant to confirm that the device is both medically necessary and being used consistently. Medicare sets strict standards: patients must demonstrate adherence to PAP therapy and attend follow-up visits with their treating practitioner. Without proper documentation, long-term coverage will not continue.

Initial 3-Month Trial Requirements

During the initial 90-day trial, BiPAP is provided on a rental basis. The machine, mask, tubing, and replacement accessories are all included. Patients remain responsible for the Part B deductible ($257 in 2025) and 20% coinsurance.

To keep coverage active, compliance must show:

• At least 4 hours of nightly use
• Usage on 70% of nights during the monitoring period
• Compliance data generated by machine downloads

Adherence is evaluated over any consecutive 30-day period during the first 90 days, and the treating practitioner must conduct a re-evaluation between days 31 and 91. Device-generated usage reports are combined with the face-to-face visit and added to the medical record.

Documentation for Long-Term Coverage

For Medicare to extend coverage beyond the trial, the treating practitioner must demonstrate ongoing benefit. This includes objective usage reports, clinical notes showing improved symptoms, and clear evidence of medical necessity.

Many BiPAP machines now provide built-in compliance technology, which makes it easier for physicians and DME suppliers to submit documentation. The LCD requires these usage reports to be filed during the 31- to 90-day compliance window.

Consequences of Non-Compliance

If a patient fails to meet compliance requirements—whether by insufficient use, missing a follow-up visit, or incomplete documentation—coverage ends. In that case, beneficiaries may need a new sleep study, updated evaluation, and a fresh trial to re-qualify. This process can delay treatment and increase out-of-pocket costs.

Costs and Financial Planning for BiPAP Therapy

Because BiPAP is more expensive than CPAP, cost planning is essential. Medicare helps by covering most expenses under the durable medical equipment benefit, but patients still face coinsurance and supply costs.

Medicare Cost Breakdown for BiPAP Machines

Medicare Part B applies its annual deductible before coverage begins. After that, patients pay 20% of the Medicare-approved amount, while Medicare covers the other 80%. BiPAP machines are rented for 13 months, after which ownership transfers to the beneficiary.

Typical cost responsibilities include:

• $240–$600 patient share for the machine after deductible
• Ongoing 20% coinsurance for replacement accessories
• Supplies such as masks, filters, tubing, and humidifiers replaced on Medicare’s set schedule

These recurring accessory costs make up a large portion of long-term expenses.

Cost Comparison and Financial Strategies

BiPAP units cost two to three times more than CPAP, although supply expenses are similar. Patients can limit out-of-pocket costs by exploring supplemental insurance or Medicare Advantage plans.

Strategies that help include:

• Selecting a Medicare-enrolled DME supplier that accepts assignment
• Considering Medigap coverage to absorb the 20% coinsurance
• Using FSA or HSA funds when eligible to cover supply costs

Proper equipment care also extends machine life, lowering replacement needs and overall spending.

Step-by-Step Guide to Getting BiPAP Coverage

The BiPAP approval process takes time, but following each step carefully improves the chances of success. Medicare requires not just medical necessity but full documentation at every stage—from diagnosis to compliance monitoring.

Phase 1: Sleep Study and Initial PAP Trial

The process begins with a consultation and referral for a sleep study. Patients undergo either an in-lab polysomnography or a home sleep apnea test, interpreted by a qualified practitioner. If results confirm obstructive sleep apnea, CPAP therapy is prescribed as the first-line treatment.

Key first steps include:

• Physician evaluation and documentation of symptoms
• Diagnostic sleep study results added to the medical record
• CPAP trial initiation with optimized settings and mask fitting

Phase 2: CPAP Failure Documentation

If CPAP is unsuccessful, the trial must demonstrate genuine effort and be thoroughly documented.

The trial should capture:

• Compliance downloads showing consistent attempts
• Adjustments to pressure and multiple mask fittings
• Face-to-face physician notes recording unresolved symptoms or intolerance

This evidence becomes the foundation for moving toward BiPAP coverage.

Phase 3: BiPAP Approval and Implementation

Once CPAP failure is documented, providers compile the sleep study, medical records, and usage data for Medicare review. Claims must include the correct HCPCS procedure codes and the KX modifier.

Next steps involve:

• For Medicare Advantage plans, submitting any required prior authorization request with supporting documentation; Original Medicare typically does not require prior authorization for PAP devices
• Coordinating delivery and setup through a Medicare-enrolled DME supplier
• Adjusting BiPAP pressure settings and optimizing comfort with equipment training
• Conducting the required re-evaluation between days 31 and 91 and confirming adherence over any consecutive 30-day period within the first 90 days using device-generated usage reports

Proper documentation at this stage prevents delays and supports long-term coverage.

Common Coverage Challenges and Solutions

Even when patients meet Medicare’s criteria, BiPAP coverage can still be denied. Most issues stem from incomplete paperwork or weak medical justification.

Frequent Medicare Denial Reasons

Denials often occur when documentation is lacking. Common issues include:

• Insufficient CPAP trial records or missing usage data
• Missing face-to-face evaluations by the treating practitioner
• Incomplete sleep study documentation in the medical record
• Provider credentials that do not meet Medicare requirements

Medicare may also reject claims if it determines CPAP adequately managed the condition, or if medical necessity for BiPAP is unclear.

Overcoming Coverage Obstacles

Patients and providers can strengthen applications by anticipating Medicare’s requirements.

Strategies that help include:

• Keeping comprehensive CPAP trial records with detailed compliance downloads
• Obtaining a specialist evaluation from a sleep medicine physician
• Working with a Medicare-enrolled DME supplier familiar with LCD requirements
• Preparing appeal documentation if initial coverage is denied

By building a strong case with objective evidence, patients reduce the risk of coverage delays and unnecessary expenses.

How a Solace Advocate Can Navigate BiPAP Coverage

The approval process is complex, but a Solace patient advocate can make it manageable. Advocates step in to coordinate providers, suppliers, and Medicare requirements so patients don’t have to handle everything alone.

Streamlining the Complex Approval Process

Advocates help patients keep the process on track by:

• Confirming CPAP trial documentation meets Medicare standards
• Scheduling required face-to-face evaluations on time
• Compiling medical records for prior authorization submissions

This coordination reduces the chance of denial due to paperwork gaps or missed steps.

Compliance and Long-Term Coverage Support

Advocates also continue helping after BiPAP is approved. Their role includes:

• Keeping patients on track with compliance downloads and follow-up visits
• Resolving equipment issues with DME suppliers
• Assisting with appeals or identifying supplemental coverage options

By guiding both the approval and compliance stages, advocates reduce stress and keep therapy accessible for patients.

FAQ: Frequently Asked Questions About Medicare Coverage for BiPAP Machines

Why can't I get BiPAP coverage without trying CPAP first?

Medicare requires CPAP as the first-line therapy because it is effective for most beneficiaries and less costly. BiPAP is covered only after CPAP intolerance or failure is documented in the medical record. This requirement is outlined in the local coverage determination (LCD) and confirmed with the KX modifier, showing coverage indications and medical necessity were met.

How long do I need to try CPAP before qualifying for BiPAP?

Medicare does not specify an exact minimum, but a genuine therapeutic trial must be documented. This includes optimized pressure adjustments, multiple mask fittings, and adherence to PAP therapy tracked through CPAP usage downloads. Typically, several weeks to three months of documented use are required. A face-to-face meeting with the treating practitioner is necessary to record diagnosis codes and confirm CPAP inadequacy.

What happens if I don't meet the 4-hour compliance requirement for BiPAP?

If adherence to PAP therapy falls short—less than 4 hours on 70% of nights—Medicare stops coverage. Without compliance, rental payments may become the patient’s responsibility. To regain eligibility, beneficiaries usually need a new sleep study, updated diagnosis codes, and a restart of the process under the Medicare Benefit Policy Manual’s coverage indications and limitations.

Can Medicare Advantage plans have different BiPAP coverage rules?

Yes. Medicare Advantage must mirror Original Medicare coverage, but prior authorization rules, contractor information section details, and billing and coding articles may vary. Plans may require specific HCPCS procedure codes, preferred DME suppliers, or alternative approval processes. Reviewing local coverage determination articles for your plan helps avoid delays, while copay structures may differ from standard Part B deductible and coinsurance rules.

Where can I find official Medicare coverage and billing information for BiPAP?

Beneficiaries and providers can consult LCD reference articles, billing and coding articles, and the Medicare Benefit Policy Manual for guidance. Key resources include contractor information sections and CPT/HCPCS procedure codes (E0470, E0471). These resources outline eligibility and documentation requirements, replacement accessories schedules, and compliance rules—helping both patients and treating practitioners prepare accurate claims for Medicare Administrative Contractors.

‍This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

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