What is the Coverage for Sleep Apnoea Treatments in Health Insurance?

Sleep Apnea & Health Insurance: What’s Covered and How to Maximize Benefits

Sleep apnoea is a sleep disorder in which breathing is interrupted and then resumed numerous times during the night. It carries severe potential consequences, including elevated high blood pressure, stroke, diabetes, and heart disease, if left untreated.

Most health insurance plans cover the diagnosis and treatment of sleep apnoea, although the extent and type of coverage can vary widely. Read ahead to understand how health insurance covers the treatment of sleep apnoea, including other necessary details.

Is Sleep Apnoea Covered as a Medical Condition?

Yes. Sleep apnoea, whether obstructive (OSA), central (CSA), or complex, is recognised as a medical condition and is usually covered under most health insurance plans. Unlike cosmetic or elective conditions, it qualifies for benefits when appropriately diagnosed by a licensed healthcare professional.

However, to be eligible to claim benefits, the condition must be clinically documented, usually requiring evidence of a sleep study.

Does Health Insurance Cover Diagnostic Tests for Sleep Apnoea?

Generally, health insurance policies cover diagnostic procedures to verify a sleep apnoea condition. Some of these standard tests include:

• Polysomnography (PSG) : An in-lab sleep study, known as polysomnography, is conducted to monitor the patient's breathing, oxygen levels, heart rate, brain activity, and body movements.
• Home Sleep Apnoea Test (HSAT) :Typically, for patients suspected of or diagnosed with moderate to severe OSA (Obstructive Sleep Apnoea), this simplified diagnostic method utilises a home-use tool to conduct a test without the inconvenience of in-lab tests.

Does Health Insurance Cover CPAP Machines and Supplies for Sleep Apnoea?

Yes, continuous positive airway pressure (CPAP) machines, which are typically prescribed by healthcare professionals, are often covered under the durable medical equipment (DME) category of most healthcare plans.

Here’s a list of other supplies that health insurance covers:

• The CPAP or BiPAP machine itself
• Initial setup and training
• Supplies such as face masks, hoses, filters, and humidifiers
• Replacement parts at regular intervals (e.g., mask every 3 months, filters monthly)

Initially, some health insurance policies provide the machine on a rental basis to confirm compliance with proper usage before granting full ownership. Most insurers consider CPAP use compliant if it is worn for at least 4 hours per night on 70% of nights within 30 days.

Does Health Insurance Cover Oral Appliances for Sleep Apnoea?

Oral therapies are usually recommended when patients are not able to cope with or tolerate CPAP machine therapy. Oral devices work by shifting the jaw or tongue to help maintain an open airway during sleep.

List of oral devices that are covered by health insurance under the following criteria:

• Must be prescribed by a licensed sleep specialist or dentist
• Must be FDA-approved for treating sleep apnoea

Does Health Insurance Cover Surgical Procedures for Sleep Apnoea?

Surgery is an option in case conservative therapies like CPAP or oral devices do not provide the required relief from the condition. The coverage is generally offered if the surgery is medically warranted and certified by a specialist. Standard surgical procedures include:

• Uvulopalatopharyngoplasty (UPPP): Involves removing excess soft tissue from the throat to help expand the airway and improve airflow.
• Maxillomandibular Advancement (MMA): Involves repositioning the upper and lower jaw permanently.
• Inspire® Therapy:Uses an implantable device that stimulates airway muscles during sleep.

Pre-authorisation is usually necessary. Surgeries for cosmetic reasons or without an apparent medical necessity are not covered.

Does Health Insurance Cover Follow-Up Visits and Monitoring for Sleep Apnoea?

Yes. Long-term sleep apnoea management may involve occasional visits to sleep specialists and periodic checks on device performance. Such visits are usually included under specialist consultation or outpatient benefits.

Coverage may also include:

• Device maintenance or recalibration.
• Repetition of sleep studies if symptoms worsen or persist.
• Replacement of faulty or outdated equipment.

Pre-approval or documentation may be required, depending on the insurer.

How to Maximise Your Health Insurance Coverage for Sleep Apnoea?

Here are a few suggestions on how to maximise your sleep apnoea coverage:

• Work with an authorised healthcare professional to obtain documentation of medical need.
• Look for providers and laboratories within your insurer's approved network.
• Complete all paperwork in a proper and timely manner.
• Adhere to prescribed treatment to facilitate compliance-based benefits.
• Know your plan's deductible, co-pay, and coverage limit.

Planning can significantly reduce out-of-pocket costs and maintain access to quality care.

Sleep apnoea is more than just a sleep disorder; it's a serious medical condition with several repercussions. Proper handling includes proper diagnosis, ongoing treatment, and monitoring, all of which can prove costly without adequate insurance coverage.