I still often hear incorrect information from dentists AND physicians regarding this common question years after oral devices have not only existed but have been recognized by many medical insurance companies.
Dental oral devices that treat apnea are covered by most medical insurance companies, especially if CPAP (continuous positive airway pressure) therapy would have been covered by that patient’s insurance. Reimbursement varies depending on the insurance but often range from 50-80% and as much as 100%. There is also a possibility of no reimbursement coverage for oral appliance therapy, although rare.
Medicare coverage for professional oral appliance therapy exists as well. However, Medicare involves stipulations as to the type of appliances covered, the diagnosis level of the patient, and time restraints after diagnosis are made. Finding a dentist who accepts Medicare for oral appliance therapy may also be a challenge.
Dental insurance should not be used for oral appliances for apnea, because apnea is a medical condition, not a dental condition. A patient would be at a disadvantage using up dental benefits for a medical condition.
Similarly to CPAP therapy, required documents will need to be submitted to the insurance carriers for oral appliance therapy reimbursement. These documents often include
- Physician-patient medical documentation of office visits discussing symptoms, diagnosis, treatments, and outcome
- A written prescription from a physician
- Results from the diagnostic sleep test.
- If exists, documentation of CPAP attempt or usage
In some cases, CPAP therapy may need to have been attempted prior to the insurance company approving oral devices. It is getting increasingly common for insurance companies to cover oral devices without the need to try and fail CPAP therapy first.
Some other points to consider:
- Medical insurance deductibles apply
- Some dentists who work with oral appliance therapy prefer not to get directly involved with medical insurance reimbursement
- A dentist must be approved DME (durable medical equipment) provider to bill Medicare.
Having experience both in the private dental office and a larger medical center, I have found there are differences in ease and reimbursements levels favoring the larger sleep facility that includes physicians and dentists working on site.
Filing medical insurance for appliance therapy is often a cumbersome process. Some experienced dental clinicians have chosen not directly work with insurance reimbursement, but instead, guide their patients to submit their paperwork to obtain benefits. Other dental sleep medicine practitioners file insurance and reimbursement as a courtesy to their patients.