By Rose Nierman, RDH, CEO of Nierman Practice Management
Oral Appliance Therapy (OAT) can be a lifesaver by reducing, not only snoring but also the many health-related side effects of Obstructive Sleep Apnea (OSA). It’s incredible that small oral appliances for sleep apnea can have such an impact on one’s health. Their main effect reduces snoring and daytime fatigue. They also reduce adverse health consequences such as high blood pressure, heart disease and “brain fog”. Oral appliances for sleep apnea are delivered by licensed dentists with training in sleep apnea appliance therapy.
With such a large impact on one’s health, the question arises as to whether insurance covers oral appliances for sleep apnea. My role as a dental speaker and advisor to dentists allows me the chance to work with high-quality dental practices that are on a mission. That mission is to help patients live better lives through healthy sleep by treating patients with OAT.
When working with dentists and their teams, the question I most hear revolves around medical insurance coverage: Are oral appliances covered through most health insurance plans? The answer to that is YES. Almost all medical plans do offer coverage for custom-made oral appliances, even though oral appliances are delivered in a dental practice setting. The reason many medical policies do provide coverage is that OSA is a medical condition that can lead to deadly consequences if left untreated.
How can I determine if my medical insurance covers my oral appliance?
Although many health insurance policies do cover custom-made oral appliances for sleep apnea, coverage depends on the language in the policy. Benefits can typically be determined with a quick call to the eligibility & benefits department using the contact numbers that are on your medical insurance card. It’s important to have a sleep study prior to the benefit verification call because the severity of OSA must be known before the benefits can be determined. Most health insurance plans categorize oral appliances for OSA as medical equipment or devices, so reimbursement is typically under the coverage for Durable Medical Equipment (DME).
This is the same benefit category for medical equipment such as electrical stimulator units for chronic pain, wheelchairs & walkers. The information provided during the benefit verification by the insurance includes the dollar amount of your deductible and how much of your yearly deductible has been met to date. Copayment amounts or percentages for coinsurance amounts are typically outlined and, most important of all, whether a preauthorization for treatment is required for coverage before you begin treatment.
Currently, there is only one medical diagnosis code available for OSA, so if you do have this condition, the diagnosis code on the sleep study is likely to be the diagnosis code G47.33, which stands for: Obstructive Sleep Apnea (adult) (pediatric). To receive preapproval, the insurance will also want to know the procedure/equipment billing code for the custom sleep appliance which is:
E0486 – ORAL DEVICE/APPLIANCE — USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
There is a good possibility that the oral appliances will require preauthorization in advance, so be sure to have the office inquire about preauthorization or precertification rules. If a preauthorization is required, it’s important to wait for approval before receiving an oral appliance.
In addition to the insurance information and sleep study, the dental practice will provide their office notes, such as the results of a screening questionnaire that indicated the presence of excessive daytime sleepiness. Medical history details that were noted during your consultation, relating to conditions such as high blood pressure or information that a person cannot wear Continuous Positive Airway Pressure (CPAP) therapy, or has refused CPAP therapy may also be required for approval of oral appliance therapy by your insurance company.
Medical plans can typically be verified in advance for coverage once you have a sleep test verifying obstructive sleep apnea.The insurance representative will want to know if you have mild, moderate or severe OSA. They may need additional information from your qualified dental sleep medicine dentist.
Medical Insurance Covers What Type of Oral Appliances?
There are over 100 FDA approved oral appliances available to dentists for custom sleep appliances. Medicare and even some commercial insurers specify that an oral appliance must be on Medicare’s published Product List to be covered.A dentist, who has training in oral appliance therapy, is qualified to recommend a custom appliance type that is right for you.
Will my medical insurance tell me how much they cover for a mouthpiece or appliance?
The insurance representative may not be able to determine the exact dollar amount of reimbursement in advance, but they will be able to tell you if you have the benefit as part of your plan.
What about deductibles. Are they as high as for other procedures?
Your deductible for this equipment can differ from your usual yearly deductible since most carriers categorize oral appliances for OSA as Durable Medical Equipment.
Equipment such as oral appliances or CPAP may carry a separate or different deductible from the one that you are used to seeing.
That is why it’s important to make sure that your policy is being checked for DME benefits.
Does Medicare offer coverage for sleep apnea oral appliances?
Medicare does provide coverage for custom oral appliances for OSA.
For a patient to receive reimbursement from Medicare for an oral appliance for sleep apnea, the treating dentist must be enrolled as a Medicare DME Supplier.
Medicare covers specific oral appliances listed as approved for reimbursement.
Your qualified dental sleep medicine will have access to this list.
Does insurance cover snoring mouthpieces?
It is important to know that while most medical insurers do offer coverage for oral appliances or mouthpieces when there is a diagnosis of OSA (verified by a sleep study), snoring alone, with an absence of OSA, is typically not a covered benefit.
Custom mouthpieces for OSA may be considered “necessary” when you have been diagnosed with mild to moderate OSA.
Also, oral appliances are sometimes covered for severe OSA if you cannot tolerate CPAP, or even in some cases where the patient simply refuses CPAP and the treatment is deemed contraindicated by your physician.
Keep in mind, “that the snore could be something more” so it’s important to have a sleep test to determine if snoring is a symptom of OSA.
Even though the snoring sounds may stop with the placement of an oral appliance, you could still be having sleep apnea episodes (stop breathing during sleep) throughout the night.
That’s why it’s important to have a follow-up sleep study following delivery of an oral appliance to make sure it’s doing its job.
When your plan does has coverage for oral appliances
The good news is that many dental practices who provide OAT have become quite adept at filing medical insurance claims, so their patients can more easily receive the care that they may need.
In order for the dental practice to communicate with your medical insurance carrier, it’s important that you provide the office with the information they will need for authorization and claim submission, starting with your medical insurance card and a copy of your sleep study, when available.
Your physician and the dental practice team are happy to assist with reimbursement by providing the clinical notes and documentation from your first visit.
As the member or “owner” of the insurance plan, you (the insured person) have the most clout to get things done and receive access to what can be potentially life-changing treatment so it’s important for you to follow up with your insurance carrier once the claim is filed.
Medical Insurance Glossary:
Allowable. The difference of what is considered “allowed” or payable is determined by your specific insurance policy, including any applicable co-pays, co-insurance, and deductibles.
Co-insurance. The percentage of the cost of treatment that is charged to the consumer for services after the insurance deductible has been paid. For example, a coinsurance level of 20 percent means that the insurance company pays 80 percent of the treatment costs, and the consumer pays 20 percent.
Co-pay. A fixed amount you pay to use a covered service. For example, you may be required to make a $50 co-payment for office visits.
Deductible. The total dollar amount you must reach before your insurance company will pay. For example, your insurance policy may have a $1,500 annual deductible. This means that you must pay $1,500 in medical bills before your insurance company pays anything.
Explanation of Benefits Form (EOB). A form sent to you by your insurance company. This form explains what payments were made by the insurance company to you or your doctor. This form also explains what unpaid amounts you owe. An Explanation of Benefits is sent by payers after the processing of a claim. EOB’s provide itemized information about claim payment information with patient responsibility amounts listed. It is important to carefully review the explanation of benefits sent from your insurance company. This document will explain why certain procedures are covered, partially covered or not covered.
Informational Forms. If you receive a letter or a questionnaire from your insurance company about a claim or a preauthorization request, respond quickly. Send your insurance company any information requested. There will be a time frame on the form or letter, so make sure that you answer within that time. Failure to do so may result in the claim being closed! Insurance companies do have their own timetables in place, so make sure you follow them!
About Rose Nierman
Rose Nierman, RDH is a pioneer in helping dentists implement medical billing. She presents workshops to dentists and dental personnel about medical billing for oral appliances for obstructive sleep apnea. She is also the President of snoringisntsexy.com. Snoring Isn’t Sexy is a resource for awareness on obstructive sleep apnea. This awareness program helps connect consumers with dentists who provide oral appliance therapy. To contact Rose and her team, request a consultation.