Medicare Advantage denied CPAP therapy? What the rule says and how to appeal.
Checked against the current rules on September 22, 2026.
A denial for CPAP therapy isn't the end of the story — Medicare Advantage plans have to follow specific coverage rules, and a denial that doesn't square with those rules is exactly the kind of appeal that tends to win.
Here's what the rule actually requires, what evidence usually turns a denial around, and the deadline you're working against.
What the rule requires
Coverage for CPAP therapy under a Medicare Advantage plan is governed byContinuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) andPositive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. A Medicare Advantage plan generally cannot apply a stricter test than what these rules require.
Questions that decide it
Before you appeal, these are the facts that usually decide whether a denial like this holds up:
Was a sleep study (in a lab or a home sleep test) actually completed?
Did the denial say the sleep study results didn't meet the coverage threshold, or that no sleep study was on file?
Has the patient been using the CPAP consistently since it started?
What a winning appeal has to show
An appeal that wins usually includes:
The sleep test (polysomnogram or home sleep test) results, showing AHI/RDI — NCD 240.4 requires an AHI/RDI of 15+ events/hour, or 5-14 with documented qualifying symptoms. (Your doctor's office provides this.)NCD 240.4
Documentation of the in-person clinical evaluation before the sleep test — LCD L33718 requires an in-person evaluation by the treating physician before the sleep test. (Your doctor's office provides this.)LCD L33718
The physician's order for the sleep test and the CPAP device — Both the test and the device must be ordered by the treating doctor. (Your doctor's office provides this.)LCD L33718
Proof of instruction on proper CPAP use and care — LCD L33718 requires the beneficiary receive instruction on device use as part of the initial coverage period. (The facility provides this.)LCD L33718
Your deadline to appeal
65 days from the date on the notice. The rule (42 CFR § 422.582) gives you 60 days from when you receive the denial, and receipt is presumed to be 5 days after the notice's own date unless shown otherwise — 60 + 5 = 65 days from the notice date.42 CFR 422.582
The plan itself then has its own clock to decide. The plan must decide within 30 calendar days for a request about a service you haven't received yet, 60 calendar days for a request about payment for something already provided, or 72 hours if the request is expedited (42 CFR § 422.590).
What to ask your doctor to address
If you're asking the treating physician for a supporting letter, it should speak to:
The sleep test's own AHI/RDI numbers and the date it was performed.NCD 240.4
If the AHI/RDI is in the 5-14 range, the specific documented symptoms (daytime sleepiness, hypertension, prior stroke, etc.).NCD 240.4
The date of the in-person clinical evaluation that preceded the sleep test.LCD L33718
Whether the patient has used the device consistently since it was provided.LCD L33718
Questions people ask
- Can the plan just say it's "not medically necessary" with no further explanation?
- The denial notice has to explain the basis for the decision and tell you how to appeal. If it doesn't point to a specific rule or criteria, that's itself worth raising in your appeal — you're entitled to know what standard was applied.
- What if I don't have all the evidence listed above?
- Include what you have. An appeal with partial evidence and a clear explanation of the rule still gets a real review — it doesn't need to be complete to be worth filing.
Sources — last checked September 22, 2026
- 42 CFR 422.582as of September 18, 2026
- Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA)as of September 22, 2026
- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apneaas of January 1, 2024
Related
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
