Alyssa Lane
Snoring is often more than just a nocturnal nuisance—it can be a symptom of sleep apnea, which affects over 36 million Americans. Sleep apnea can lead to serious health issues, including heart and lung disease, high blood pressure, and diabetes. If you're seeking to treat your snoring with a device, you may be wondering if medical insurance will cover it. The short answer is that it depends on the insurance plan and the context. Most medical insurers do not cover snoring devices if snoring is the only issue, but they may cover oral appliances or mouthpieces if you have a diagnosis of obstructive sleep apnea (OSA).
| Characteristics | Values |
|---|---|
| Diagnosis Code | ICD diagnosis code G47.33 |
| Billing Code | E0486 |
| Pre-authorization | Required |
| Sleep Study | Required |
| Sleep Study Types | In-lab polysomnogram (PSG), Home Sleep Tests (HST) |
| Sleep Study Requirements | Sleepiness questionnaire scores (Epworth Sleepiness Scale), clinical notes from the sleep apnea screening appointment, CPAP refusal or intolerance affidavit |
| Other Requirements | Copy of physician's written order (prescription for the oral appliance), "Proof of Delivery" form |
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What You'll Learn
A sleep study is required for pre-authorisation
To submit a snoring device through medical insurance, you will need to determine whether your insurance plan covers such devices. Snoring alone is not a covered benefit for most insurers, but if you have a diagnosis of obstructive sleep apnea (OSA), your insurance may cover an oral appliance.
Prior authorization is often required by insurance providers to maintain healthcare costs within defined limits and to ensure that the procedure is carried out by qualified personnel in an accredited facility. The pre-authorisation process may vary depending on the insurance provider, so it is important to communicate with them directly to understand their specific requirements.
To initiate the pre-authorisation process, you will need to provide the insurance company with the patient's personal and insurance information, including their full name, address, date of birth, contact details, insurance provider name, ID/policy number, and the requested sleep study service codes. The insurance company will then verify the patient's coverage details, such as deductibles, copays, and policy limitations, to determine their financial responsibility for the recommended services.
It is important to note that Medicare, a program for seniors and people with certain disabilities, does provide coverage for custom oral appliances for OSA. However, the treating dentist must enroll their practice location as a Medicare DME Supplier by submitting an application using the form CMS 855S.
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Medical insurers cover oral appliances with an OSA diagnosis
Oral appliances for sleep apnea can be life-saving, and they can also save relationships. Many dental offices find it rewarding to help patients manage obstructive sleep apnea (OSA) with oral appliance therapy (OAT). Most medical plans offer coverage for custom-made oral appliances, but it's important to prepare for insurance requests for paperwork.
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 stimulators for pain, wheelchairs, and walkers. The deductible for oral appliances may differ from the yearly deductible for other services since most carriers categorize oral appliances for OSA as DME.
To receive pre-approval, the insurance company will 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. There is a good possibility that the oral appliance will need to be pre-authorized in advance, so be sure to inquire about pre-authorization rules. If a pre-authorization is required, it’s important to wait for the approval before delivering the oral appliance.
Most commercial carriers reimburse for an OSA screening exam with the submission of evaluation and management codes. There are also cross-codes from dental to medical for the radiographs. When billing for exams, it’s important to keep detailed clinical notes showing your medical history and clinical exam so that you can use a medical office visit code. The good news is that there is no frequency on the exam and x-ray codes with medical insurance like there is for dental, so if a patient needs an exam three months after a previous exam, the insurance will typically reimburse for both.
According to the Centers for Disease Control (CDC), more than 36 million Americans suffer from some form of sleep apnea. Individuals with sleep apnea experience short periods when breathing is momentarily stopped or slowed. This disturbance to breathing can lead to serious illness, including heart and lung disease. Snoring is a common symptom of sleep apnea, and it can be a sign that your breathing is disrupted during sleep.
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Medicare covers custom oral appliances for OSA
Medicare does provide coverage for custom oral appliances for OSA. However, it is important to note that snoring alone, without an OSA diagnosis, is typically not covered by medical insurance. Oral appliance therapy is a treatment for obstructive sleep apnea (OSA), which affects over 36 million Americans. During an apnea event, the person will temporarily stop breathing for at least 10 seconds, which can lead to serious health issues.
To receive Medicare coverage for an oral appliance, the treating dentist must be enrolled as a Medicare Durable Medical Equipment (DME) Supplier. The dentist can then bill Medicare for the oral appliance, and receive reimbursement. To become a licensed DME supplier, an application can be submitted using form CMS 855S. Once a facility becomes a DME supplier, all dentists practicing at that location are authorized for Medicare reimbursement.
To receive pre-approval for an oral appliance, you will need to provide the billing code: E0486 – ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON- ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT. It is also important to check your benefits to ensure coverage is available, and you may need to request pre-authorization.
Medicare covers specific oral appliances listed as approved for reimbursement, and your qualified dental sleep medicine provider will have access to this list. Medicare specifies that an oral appliance must be on their published Product List to be covered. A custom device is covered when a prefabricated appliance cannot accommodate an anatomical abnormality.
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Medical insurance covers sleep apnea treatment
Sleep apnea is a condition that affects over 36 million Americans, causing breathing to stop or slow down temporarily during sleep. This can lead to serious illnesses such as heart and lung disease if left untreated. The good news is that medical insurance typically covers sleep apnea treatment, making it more accessible and affordable for those suffering from this condition.
To understand how medical insurance can help with the cost of sleep apnea treatment, it is essential to first grasp the treatment process. Usually, the initial step is to visit a doctor, who will then refer you to a sleep specialist for a sleep test or sleep study. If sleep apnea is diagnosed, treatment options may include CPAP therapy, oral appliance therapy, or, in rare cases, corrective surgery. Due to the significant health risks associated with sleep apnea, medical insurance generally covers the various stages of treatment, including examinations, testing, treatment, and follow-up visits.
It is important to note that dental plans typically do not provide reimbursement for sleep apnea treatment. However, medical insurance can offer reimbursement for oral appliances, which are considered "durable medical equipment (DME)." To ensure coverage, carefully review your insurance policy and, if necessary, contact your provider for clarification. It is also helpful to prepare for insurance requests for paperwork, which may include a copy of the sleep study, sleepiness questionnaire scores, clinical notes from the sleep apnea screening, and a CPAP refusal or intolerance affidavit.
While snoring alone is typically not a covered benefit, oral appliances for treating sleep apnea can also help reduce snoring. These oral devices gently hold the jaw forward to keep the airway open, improving sleep quality and reducing snoring. Therefore, seeking a diagnosis and treatment for sleep apnea can address both the health risks associated with apnea events and the inconvenience of snoring.
In summary, medical insurance typically covers sleep apnea treatment, including oral appliances, making it more accessible and affordable for those suffering from this condition. By understanding the treatment process and reviewing insurance policies, individuals can effectively manage the costs associated with sleep apnea diagnosis and treatment.
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Oral appliances are considered durable medical equipment
Oral appliances are considered "durable medical equipment (DME)" and are covered by most medical insurance companies. However, it is important to note that snoring alone is not a covered benefit. Oral appliances are typically covered for individuals with a diagnosis of obstructive sleep apnea (OSA).
To receive coverage for an oral appliance, you must first obtain a diagnosis of OSA through a sleep study. This study can be conducted in a laboratory or at home, and the results will determine the severity of your OSA. After the sleep study, you will need to obtain a prescription for the oral appliance from your dentist or physician. It is important to check with your insurance provider to see if they require a home or laboratory sleep study and if preauthorization is required before delivering the oral appliance.
Once you have the necessary documentation, you can submit a claim to your insurance provider for reimbursement. The reimbursement process may vary depending on your insurance plan and the specific oral appliance you have purchased. Some insurance plans may have a separate deductible specifically for DME, so be sure to check your policy for DME benefits.
When submitting your claim, you will need to provide 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. Additionally, you may need to provide the ICD diagnosis code for OSA, which is G47.33.
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Frequently asked questions
Snoring alone is typically not covered by medical insurance. However, if snoring is a symptom of Obstructive Sleep Apnea (OSA), oral appliances or mouthpieces may be covered by insurance.
OSA is a condition where individuals experience short periods when breathing is momentarily stopped or slowed. According to the Centers for Disease Control (CDC), over 36 million Americans suffer from some form of sleep apnea.
It is important to get a sleep test to determine if snoring is a symptom of OSA. A sleep study is usually required as part of pre-authorization for a dentist billing medical insurance for sleep apnea.
You will need to submit a copy of the sleep study, sleepiness questionnaire scores (Epworth Sleepiness Scale), clinical notes from the sleep apnea screening appointment, and a CPAP refusal or intolerance affidavit. You may also need a copy of the physician's written order (prescription for the oral appliance) and a ""Proof of Delivery" form signed by the patient.
