In many cases, health insurance will cover all or part of the costs of getting an oral appliance for sleep apnea treatment. This can vary from one insurance plan to another, or from state to state. Some insurers may cover the full cost, while others may cover part of the cost.
How can I predetermine if medical insurance covers an oral appliance? Start by making a call to the benefits department using the contact numbers from the patient’s medical insurance card. It’s important to have sleep study information before the benefits verification call because the severity of OSA must be known before the benefits can be determined.
What are the billing codes? Today, there is only one medical diagnosis code available for OSA, the diagnosis code on the sleep study will be ICD diagnosis code G47.33, which stands for Obstructive Sleep Apnea (adult) (pediatric). To receive pre-approval, the insurance will also want to know the 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
Best practice is to preauthorize in advance. If a preauthorization is required, it’s important to gain the approval before delivering the oral appliance.
What type of oral appliances are covered by medical insurance?There are over 100 FDA-approved oral appliances available to dentists for custom sleep appliances. Medicare specify that an oral appliance must be on Medicare’s published Product List to be covered. There are limited products available on the Medicare lists, this is because of the description and policy of the product was written a decade ago, and the newer appliances on the market while more innovative, comfortable and desirable may not be covered.
When Medicare or a commercial payer is following the CMS policy for reimbursement and a patient wants a non-covered appliance then an ABN form ( Advanced Beneficiary Notification form ) can be signed by the patient, this allows the dental provider to bill Medicare, receive a denial of payment and then legitimately bill the patient. But only if the ABN has been signed in advance of billing the patient.
Does insurance cover snoring devices? Snoring alone is not covered by medical insurance, however snoring is a symptom of sleep apnea and if OSA is diagnosed then most medical insurers offer coverage for oral appliances with a diagnosis of OSA. benefit. Oral appliances are typically covered for severe OSA if the patient cannot tolerate CPAP or in some cases if the patient refuses CPAP. (however check with your medical payer first!)
What about deductibles? The deductible can differ from the yearly deductible for other services since most carriers categorize oral appliances for OSA as Durable Medical Equipment (DME). It is important to make sure that the patient or provider check the policy for DME benefits.