Does Medicare Cover Inspire for Sleep Apnea?

OSA is a sleep disorder involving repeated pauses in breathing during sleep. These breathing lapses occur when the airway at the back of the throat becomes blocked by the collapse of the airway or the tongue blocking the airway.

Inspire (also referred to by its generic name, hypoglossal nerve stimulation) is an increasingly common treatment for OSA. It is an FDA-approved treatment that requires implanting a small device in the upper chest under the skin. During sleep, the device sends electrical signals to the nerve that controls the muscles of the tongue and surrounding structures, activating them and reducing breathing disruptions. 

Medicare doesn’t cover Inspire treatment in all cases, so it’s important to understand the program’s rules and regulations. We go over the details of how Inspire works, when it’s covered by Medicare, and the steps to secure Medicare coverage for this sleep apnea treatment.

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How Inspire Works for Sleep Apnea

Inspire works by implanting a device in the body that gently stimulates certain nerves so that muscles around the airway are engaged. This helps keep your airway open while you sleep. 

In technical terms, this type of therapy is called hypoglossal nerve stimulation (HNS), and Inspire is formally known as the Inspire Upper Airway System. Inspire is an FDA-approved type of hypoglossal nerve stimulation therapy for obstructive sleep apnea.

Inspire therapy requires a short outpatient surgery. During the operation, a small device is placed under your skin near your collarbone via a small incision. Another incision is made near your jaw to link the device to the nerves in the neck that control the upper airway muscles. 

As you sleep, the device sends small pulses of electricity to the nerves using a sensor to align the pulses with your breathing. The Inspire device is programmed by your doctor, and you can turn it on and off with a remote. 

The recurring electrical pulses help keep muscles from slackening and blocking the airway. The nerve stimulation also prevents the tongue from sliding back and obstructing breathing.

When the Inspire device is working, you may feel light muscle movements, but the treatment does not cause pain. After turning on the device, the pulses are delayed for 20 minutes, giving you time to fall asleep before the stimulation begins. 

Medicare Coverage of Inspire for Sleep Apnea

Medicare plans provide coverage for Inspire for obstructive sleep apnea, but only under certain circumstances.

For example, Medicare will only cover Inspire for OSA if you have had a sleep study within the last two years, have moderate to severe sleep apnea, and either can’t use a CPAP machine or have already tried CPAP therapy without success.

Even if you meet the criteria for coverage, Medicare doesn’t pay for everything. Before Medicare starts paying, you must meet your Medicare Part B deductible, which is $283 in 2026. After that, you are usually responsible for a coinsurance of 20%, although you may pay less if you have a Medicare supplement (Medigap) plan.

How to Get Medicare to Cover Inspire

Knowing the requirements and working closely with your doctor are essential steps to getting Medicare coverage for Inspire therapy for sleep apnea.

Medicare Requirements for Inspire Coverage

Medicare has very specific rules about coverage of Inspire treatment for OSA. To qualify, you must meet all of these requirements: 

• Age: You must be over 22 years old. 
• BMI: Medicare requires that your body mass index (BMI), which is determined by your height and weight, be lower than 35 (potentially up to 40, depending on your local coverage determination, or LCD).
• Recent sleep apnea testing: The sleep study used to diagnose you with OSA must have been conducted within the last two years.
• OSA severity: You are only eligible for Inspire coverage if you have OSA that is considered moderate to severe. This is determined using the number of sleep disruptions you had during the sleep study, represented by a metric called the apnea hypopnea index (AHI). 
• Lack of benefit from CPAP therapy: To get coverage, you must have tried CPAP therapy without success. You may also be eligible for Inspire if your doctor determines that you aren't able to use a CPAP machine and need a CPAP alternative. However, Medicare generally needs objective documentation of CPAP intolerance.
• Cleared by the results of an endoscopy: During a special sleep endoscopy, doctors must confirm that the soft palate doesn’t collapse inward from all sides at once, which would make Inspire ineffective.
• Contraindications: You can’t have other health issues — including some serious heart or lung conditions — that could affect or be affected by the Inspire procedure or nerve stimulation therapy. You may also be ineligible if you have both OSA and central sleep apnea (CSA).

To qualify for coverage, you need to work with a doctor who can document in your medical record that you meet all of these criteria. 

In addition, Medicare requires that the procedure be performed by a Board-certified head-and-neck doctor with specific training in Inspire therapy. The doctor must also be enrolled in Medicare, accepting Medicare’s rules and payments. 

Cost of Inspire With Medicare

If you qualify for Medicare coverage for Inspire, you will still have out-of-pocket costs. According to Medicare data, the average patient cost at a hospital outpatient department is $1,839. The average patient cost if the procedure is done at an outpatient surgical center is $5,329. There may be additional costs, such as separate fees for your ENT surgeon and anesthesiologist, post-implant programming visits, and DISE procedure.

Remember that these are averages, and your actual cost will vary by location. However, Medicare caps out-of-pocket costs for outpatient procedures at hospitals, which is why it typically costs less to have Inspire implanted at a hospital than at an outpatient surgical center. 

Similarly, your cost will depend on your provider and how they participate in Medicare. If a provider “accepts assignment” for your Medicare claim, it means they only charge Medicare’s established cost for the procedure. Working with a provider who accepts assignment can lower your expenses and simplify the claims process.

If you work with a provider who is enrolled in Medicare but does not accept assignment, you may have higher out-of-pocket costs because the provider can charge more than the amount that Medicare pays. If your provider is not enrolled in Medicare, you will not have any coverage at all for the procedure.

How to Check if Your Medicare Plan Covers Inspire

The best way to confirm that your plan covers Inspire is to contact your insurance provider directly. You can usually find a customer service phone number on your insurance card or can contact the provider through their website.

If you have a Medicare Advantage plan, it must provide coverage for Inspire under the same conditions as Original Medicare. However, your network of providers and out-of-pocket costs may be different. Check with your Medicare Advantage insurance company for Inspire coverage details.

If you have a Medicare supplement plan, it may pay for some out-of-pocket costs that are not covered by Medicare. Contact your insurer to learn how the supplemental plan applies to Inspire.

Written by

Eric Suni, Contributing Writer

Eric Suni has over a decade of experience as a science writer and was previously an information specialist for the National Cancer Institute.

Reviewed by

Pranshu Adavadkar, MD, Medical Reviewer

As a board-certified sleep medicine physician with over 20 years of clinical experience, Dr. Adavadkar is an expert in diagnosing and treating sleep disorders in both children and adults, as well as addressing sleep issues experienced by veterans. While practicing primary care after completing his pediatric residency at John H. Stroger Jr. Hospital of Cook County in Chicago, he developed a strong passion for sleep medicine. He observed the prevalence and intricacy of sleep problems and the significant effect they had on his patients\' and their families\' well-being, leading him to recognize this as a field where he could make a meaningful impact on people\'s lives.