Does Medicare Cover Inspire for Sleep Apnea?

Key Takeaways

• Inspire is a sleep apnea treatment that uses an implanted device to stimulate the nerve that controls the tongue to keep the airway open during sleep.
• Medicare may cover Inspire — typically under Medicare Part B — but only when it’s deemed medically necessary and after CPAP and other treatments have been tried unsuccessfully.
• Strict eligibility criteria apply, including age requirements, sleep apnea severity, CPAP intolerance, recent sleep study results, appropriate airway anatomy, and BMI.

What Is Inspire for Sleep Apnea? 

Inspire reduces episodes of stopped breathing by stimulating the nerve that controls the tongue. The device consists of a nerve stimulator, as well as a sensor and generator that keep track of your breathing patterns. These are implanted near your collarbone and run on batteries that last around a decade.

When you breathe in, the nerve stimulator activates muscles to move your tongue forward and widen the airway. Your doctor has access to a programmer to adjust the settings, and they’ll give you a remote control so you can turn the generator on and off every night.

Does Medicare Cover Inspire for Sleep Apnea?

For certain people with moderate to severe OSA who cannot tolerate CPAP therapy and aren’t candidates for surgery, hypoglossal nerve stimulation is considered an effective treatment option. Where medically necessary, Medicare covers the cost of the Inspire device and the implantation procedure, as well as revision, replacement, or removal. As an outpatient procedure, Inspire generally falls under Medicare Part B.

How Do You Get Medicare to Cover Inspire?

To obtain Medicare coverage, you must go through the formal sleep apnea diagnosis process and be sure to select a provider that accepts Medicare assignment. Your healthcare team is responsible for selecting the right codes to obtain Medicare coverage, including codes for your Inspire diagnosis and codes indicating your BMI, as well as the codes for the applicable procedure. They can provide guidance on the claims process.

OSA is preferentially treated with continuous positive airway pressure (CPAP) therapy. Generally, first, Medicare will cover CPAP therapy and only pays for your Inspire treatment once you’ve proven that CPAP therapy and other sleep apnea treatment options aren’t working for you.

What Are Medicare’s Requirements for Inspire Coverage?

To obtain Medicare coverage for Inspire, you must meet a set of criteria. These criteria are based on studies that have shown the most benefit for people with a certain health profile.

• Age: You must be at least 22 years old. Younger people with Down syndrome may qualify.
• Weight: You must have a body mass index (BMI) under 35.
• Polysomnography: You must undergo a sleep study within 24 months of your first Inspire-related doctor’s appointment.
• Sleep apnea type: Inspire is intended for people with obstructive sleep apnea, rather than central or mixed sleep apnea.
• Severity: You must have an apnea-hypopnea index of 15 to 65 events per hour, otherwise known as moderate to severe sleep apnea.
• History of CPAP use: You should be able to prove that you’ve tried CPAP therapy and it didn’t work for you.
• Soft palate: Inspire isn’t recommended if you have complete concentric collapse of the soft palate (aka, if the back of your mouth is completely blocked).
• Other anatomical considerations: You should not have any other anatomical reasons that would interfere with Inspire, such as large tonsils.

Medicare won't cover Inspire if you have certain coexisting medical, psychiatric, or sleep conditions or if you are pregnant. You may need additional medical advice if you have other implanted devices, as these may interfere with Inspire if they’re too close.

Medicare may ask for additional proof, such as transcripts from your doctor’s visits or video clips from a drug-induced sleep endoscopy that prove you don’t have complete concentric collapse of the soft palate.

To qualify for Medicare coverage, the Inspire implantation procedure must be done in an appropriate setting by a qualified professional.

How Much Does Inspire Cost With Medicare?

Your copayment for Inspire implantation depends on whether you have the procedure done in an ambulatory surgical center or in a hospital outpatient department. You can expect to pay roughly $5,000 in an ambulatory surgical center, versus just under $2,000 in a hospital outpatient department.

These costs are average and may vary, depending on your personal situation and where you’re located. If you’re enrolled in Original Medicare, your copayment in a hospital outpatient department may be capped at a maximum of $1,676. If you haven’t yet met your annual Part B deductible, you may need to pay that as well. The Part B deductible in 2026 is $283.

There may also be additional costs if you require more than one doctor. You may also need to pay a copayment to the hospital. Medicare may cover additional costs for sleep studies or follow-up appointments, but you may need to contribute a copay. If you have a plan such as Medigap that covers additional costs, your copayment may be lower.

How Do You Check if Your Medicare Plan Covers Inspire?

Your Medicare plan should cover Inspire with an approved provider if you have Medicare Part B. Usually, claims are processed by the healthcare team. If you’re registered with Original Medicare, talk to your healthcare provider about applying for coverage. 

You can contact Medicare directly or your local State Health Insurance Assistance Program (SHIP) for help if you still have questions. If you use a supplemental plan like Medigap or Medicare Advantage, contact the insurance company that manages the plan.