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Are Sleep Studies Covered by Insurance?
- Most Medicare, Medicaid, and private insurance plans cover sleep studies when they’re medically necessary.
- Insurance generally covers several types of sleep tests, including in-lab polysomnography, at-home sleep tests, and follow-up or CPAP titration tests.
- Insurance often requires prior authorization and documentation of your symptoms before approving coverage.
- Out-of-pocket costs vary by plan: Medicare pays 80% after deductible, while Medicaid usually has minimal cost-sharing. At-home tests generally cost less than in-lab studies.
Sleep studies are an important diagnostic tool that help doctors identify a number of sleep disorders and determine proper treatments, but the cost can vary widely, depending on the type and location. The good news is that in most cases, insurance covers sleep studies and limits out-of-pocket costs.
Below, we’ll walk you through the types of sleep studies insurance may cover, different plans, factors that affect coverage, and how much you should expect to pay.
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Does Insurance Cover a Sleep Study?
Insurance plans, including Medicaid and Medicare, typically cover sleep studies, but only if they’re medically necessary. In other words, a doctor must determine that a sleep study is needed to help diagnose a disorder based on your symptoms and medical history. Your doctor will provide you with a referral to a sleep clinic or a prescription for a home sleep test to submit to your insurance.
What Types of Sleep Studies Does Insurance Cover?
Insurance plans generally cover several types of sleep studies, though the specific coverage may vary by insurer or plan.
In-Lab Polysomnography
In-lab polysomnography (Type I) is the most comprehensive type of sleep study. You spend a night in a sleep clinic and wear devices that let technicians monitor your brain waves, heart rate, breathing, oxygen levels, and body movements.
Home Sleep Test (HST)
At-home sleep tests (Types II, III, or IV) allow you to take the test in your own bed using portable monitoring equipment. These tests are less comprehensive than polysomnography but have been found effective for diagnosing sleep apnea.
Follow-Up or CPAP Titration Studies
If you’re diagnosed with sleep apnea, you may need a follow-up study to determine the right CPAP pressure settings. During a CPAP titration study, technicians or healthcare providers try different pressure settings on your CPAP machine to find the ideal level for your treatment and comfort.
What Insurance Plans Typically Cover Sleep Studies?
Private health insurance, Medicare, and Medicaid all cover sleep studies, but the level of coverage and the requirements vary according to your plan.
Private Health Insurance
Private insurance plans generally cover sleep studies ordered by your healthcare provider, but often include conditions and rules that may vary depending on your plan.
- Referrals: HMO plans often require a referral from your primary care physician, while PPO plans usually do not.
- Prior authorization: Depending on your insurance plan and the type of sleep study, you may need approval from your insurance company before scheduling the test. Your doctor must submit documentation showing why the test is medically necessary.
- In-network providers: Using an in-network sleep clinic typically results in lower out-of-pocket costs. Some plans may not cover out-of-network providers.
- Cost-sharing: You may be responsible for copays, coinsurance, or your deductible, depending on your plan.
Medicare
Medicare Part B covers Type I, II, III, and IV sleep tests when you have clinical signs and symptoms of sleep apnea documented in your medical record and your doctor orders the test.
- In-lab tests (Type I): This type must be performed in an accredited sleep lab facility.
- Home sleep tests (Types II-IV): These can be performed at home or in a sleep lab, attended or unattended.
After meeting the Part B deductible, you pay 20% of the Medicare-approved amount.
Medicaid
Medicaid coverage for sleep studies varies by state and type of study, but cost sharing is usually minimal. Check with your state’s Medicaid program for specific coverage requirements.
What Affects Whether a Sleep Study Is Covered?
Several factors determine whether your insurance will cover a sleep study and how much you’ll pay.
Medical Necessity
Insurance companies only cover sleep studies when they’re medically necessary. Your doctor needs to document symptoms that suggest a sleep disorder, such as:
- Chronic, loud snoring
- Witnessed breathing pauses or gasping during sleep
- Excessive daytime sleepiness despite adequate sleep time
- Morning headaches
- Insomnia
- Sleepwalking
- Leg discomfort or movement at night
- Problems moving or speaking upon waking up
Prior Authorization
Many insurers require prior authorization before they’ll cover a sleep study. This means your doctor must submit a request to your insurance company explaining why the test is medically necessary. This request will likely include:
- Your symptoms
- Your medical history (including any previous sleep studies)
- Necessary codes and information about the accredited sleep facility if applicable
In-Network vs. Out-of-Network Providers
Using an in-network sleep center typically results in significantly lower costs. In-network providers have contracted rates with your insurance company, and you’ll only pay your plan’s copay or coinsurance.
If you choose an out-of-network sleep center, you’ll likely face higher copays or coinsurance percentages, or in some cases, you may have to pay the entire cost out of pocket.
Type of Sleep Study
HSTs generally cost less than in-lab studies. For this reason, many insurance companies prefer that you start with an HST if you’re being tested for sleep apnea. However, an in-lab test may be necessary if you have other medical conditions, if you’re being tested for a condition other than sleep apnea, or if your HST proved inconclusive.
How Much Does a Sleep Study Cost With Insurance?
Your costs for a sleep study depend on your insurance plan and whether you’ve met your deductible.
Typical Out-of-Pocket Costs
- With a copay: You’ll pay a flat fee decided on by your insurance company.
- With coinsurance: You’ll pay a percentage of the total cost. For example, if you have 20% coinsurance and take an HST costing $200, your out-of-pocket cost would be $40.
- Deductibles: You may need to pay the full cost of the sleep study until you meet your annual deductible. For example, if you have a $2,000 deductible and haven’t spent any money toward it in the year, you would likely pay the entire cost of the sleep study.
Cost Differences Between Study Types
- Home sleep test: Typically $100 to over $1,000 total cost. With insurance, you might pay $50 to $200 after cost-sharing, depending on your plan and if you’ve met your deductible.
- In-lab studies: An average of $3,000 total cost. With insurance, you might pay $200 to $600, depending on your plan and if you’ve met your deductible.
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Brian Clark is a writer and educator based in Los Angeles. His articles have appeared in The Austin Chronicle, Movieline and Screen Anarchy, among others. Like many, he became acutely aware of the importance of sleep after his first child was born.
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