If you’ve recently been diagnosed with obstructive sleep apnea and your doctor has recommended a CPAP machine, you’re probably eager to start treatment. But before your equipment is delivered, you may hit a frustrating pause: prior authorization.
This step, often required by insurance providers, can delay your care unless you understand how it works and what’s needed to move things forward.
What Is Prior Authorization?
Prior authorization (also known as pre-authorization or pre-certification) is a process used by health insurance companies to verify the medical necessity of a treatment before they agree to cover it.
In the case of CPAP (Continuous Positive Airway Pressure) machines, insurers want to confirm that:
- You’ve been properly diagnosed with obstructive sleep apnea (OSA)
- You’ve completed approved testing
- A physician has prescribed CPAP as the appropriate treatment
This requirement applies whether you’re using a home sleep test or had an in-lab polysomnography.
According to CMS guidelines, Medicare and many commercial payers won’t pay for a CPAP device without documentation of moderate to severe OSA and clinical need.
Why Is It Required?
While it might seem like red tape, prior authorization is meant to:
- Prevent overuse of medical equipment
- Ensure the treatment fits your diagnosis and severity
- Keep insurance costs manageable
Because CPAP machines are considered durable medical equipment (DME), they fall under different review rules than medications or procedures.
Unfortunately, that also means more paperwork and wait times—especially if your provider or supplier isn’t familiar with your insurance plan’s exact documentation needs.
What Documents Are Needed for CPAP Approval?
To meet most prior authorization requirements, your provider must submit:
- Sleep study report (showing AHI ≥5 with symptoms, or AHI ≥15 without)
- Physician’s prescription for CPAP therapy
- Clinical notes showing daytime symptoms (e.g., fatigue, sleepiness)
- Documentation that an evaluation took place (in person or via telehealth)
Some insurers also request:
- Proof of a trial period with CPAP and evidence of compliance
- Confirmation that other causes of sleepiness were ruled out
Your DME provider usually handles the submission—but delays happen if documentation is missing or the diagnosis is unclear.
How Long Does Prior Authorization Take?
It varies based on:
- Insurance provider
- Completeness of paperwork
- Whether additional clarification is needed
Typical turnaround times range from 3 to 14 business days. Some insurers offer real-time electronic portals that speed up approvals. Others may take longer if the request is flagged for manual review.
If you haven’t heard anything after 7 days, follow up with both your doctor’s office and your DME provider to confirm status.
What If Prior Authorization Is Denied?
If your request is denied, it doesn’t mean you’re out of options. Here’s what you can do:
-
Request a Peer-to-Peer Review
Your doctor can speak directly with an insurance reviewer to explain your case.
-
File an Appeal
You (or your provider) can submit a formal appeal with additional documentation.
-
Switch Testing Pathways
Sometimes, switching from a home test to a full polysomnography can satisfy insurer requirements—especially if your symptoms are severe but home results are borderline.
-
Ask About Cash Pay Options
Some suppliers offer lower out-of-pocket pricing if you’re unable to wait for approval.
Appeals are often successful when they include:
- Clear documentation of symptoms
- Clinical evidence showing daytime impairment
- A physician’s explanation of why CPAP is medically required
How to Speed Up the Process
Prior authorization can feel like a black box, but here’s how to make it move faster:
Choose a provider familiar with your insurance network
Make sure your sleep test includes complete AHI data
Ask your doctor to write a clear CPAP prescription
Submit all documents at once, not in pieces
Follow up with your DME supplier every few days
If you’re using a home sleep testing service, make sure they offer MD review and documentation that meets your insurance carrier’s criteria.
Some telemedicine sleep platforms streamline this by bundling:
- Testing
- MD sign-off
- Insurance-ready documentation
- Equipment delivery post-approval
Does Prior Authorization Mean I’m Approved Forever?
Not always. Some insurance plans have a 90-day compliance period, especially Medicare.
This means you must:
- Use the CPAP machine consistently (usually ≥4 hours/night, 70% of nights)
- Upload usage data from the device
- Complete a follow-up appointment to confirm benefit
If you don’t meet these requirements, insurance may stop covering rental fees or refuse to convert the rental to a permanent purchase.
Read more on Medicare’s CPAP compliance rules.
Bottom Line: Don’t Skip the Authorization Step
If you’ve been prescribed a CPAP machine, prior authorization may sound like a hassle—but skipping it can lead to delays, unexpected bills, or denied claims.
Instead:
- Work with providers who understand the documentation process
- Ask early what your insurance requires
- Follow up to make sure paperwork is moving
- Use the approval to unlock access to the therapy that can improve your energy, memory, and overall health
A few days of paperwork now can lead to years of better sleep—and that’s worth the wait.
