In many cases, health insurance will cover all or part of the costs of obtaining an oral appliance for obstructive sleep apnea (OSA) 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 check to determine if medical insurance covers an oral appliance? Call the insurer/policy holder benefits department using the contact numbers from the patient’s medical insurance card. It is important to have the sleep study results and other medical information before the benefits verification call to ensure medical eligibility and necessity. The patient must meet certain criteria before the benefits can be determined.
What are the billing codes? There is only one medical diagnosis code for OSA, which is ICD-10 diagnosis code G47.33, which stands for Obstructive Sleep Apnea (adult) (pediatric). To receive pre-approval, the insurance provider 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
To better serve patients, best practice is that the provider obtains authorization and approval before ordering and delivering the oral appliance.
What type of oral appliances are covered by medical insurance? Oral appliances that are coded E0486 are typically covered if considered medically necessary and the patient meets certain criteria. Oral appliances may be 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). If your patient is on Medicare, not all appliances are approved and covered by Medicare.
For Medicare coverage to be allowed, the product must undergo evaluation, and be published to an approved list. This evaluation is carried out by the Pricing, Data Analysis, and Coding (PDAC) who are contractors to the government. PDAC reviews the product and if it matches the established criteria, they then recommend a proper code for billing. The O2Vent Optima device has been assigned the HCPCS Code of E0486 for Medicare reimbursement. Click here to link to E0486 information. Additionally, some commercial insurance payers also require this approval as they have adopted Medicare guidelines.
Does insurance cover snoring devices? An oral appliance for 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.
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.