Haris Ashley
Oral appliance therapy for sleep apnea is a treatment option that can save lives and relationships. It is covered by most medical insurance companies, and Medicare coverage is also available. However, the process of filing for medical insurance for appliance therapy can be cumbersome, and it is important to note that dental insurance should not be used for oral appliances for apnea, as it is a medical condition. To submit a dental sleep device for medical insurance, the patient's insurance eligibility must be checked, and pre-authorization may be required. A sleep study, along with other documentation, is typically necessary for the insurance company.
How to submit dental sleep devices for medical insurance
| Characteristics | Values |
|---|---|
| Required documents | 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. |
| Other required documents | Copy of the physician's written order (prescription for the oral appliance), patient-signed "Proof of Delivery" form, medical histories documenting high blood pressure, daytime sleepiness, cognitive or mood disorders, heart disease, and other consequences of sleep apnea |
| Sleep study types | In-lab polysomnogram (PSG), at-home sleep tests (HSTs) |
| Insurance coverage | Most medical plans offer coverage for custom-made oral appliances. Medicare covers oral appliances for sleep apnea. |
| Reimbursement | Reimbursement varies depending on the insurance but often ranges from 50-80% and as much as 100%. |
| Preauthorization | The oral appliance will likely need to be preauthorized in advance. |
| DME supplier | An application can be submitted to become a licensed DME supplier using the form CMS 855S. |
| Billing and coding | Billing codes for custom sleep appliances: E0486 – ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON- ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT. ICD diagnosis code for OSA: G47.33. |
| Relationship with physicians | Building relationships with local physicians can help gain the trust of the medical community. |
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What You'll Learn
Sleep study requirements
Sleep studies are a critical component of the pre-authorization process for dental billing of medical insurance for sleep apnea. While the specific requirements may vary depending on the insurer, here are the general sleep study guidelines to follow:
Firstly, it is important to note that different types of sleep studies are available, and the regulations for prescribing them may differ. The gold standard is an in-lab polysomnogram (PSG), which requires patients to spend the night in a lab for comprehensive monitoring. However, this option may be inconvenient and less feasible for some patients. Fortunately, with very few exceptions, insurers accept the results of at-home sleep tests (HSTs). HSTs are minimally invasive, allowing patients to collect data on airflow, arousal, and blood oxygen levels during sleep in the comfort of their homes.
When submitting for medical insurance, a copy of the sleep study results is typically required. This can include data from either an in-lab PSG or an HST, depending on what is feasible and acceptable to the insurer. Additionally, sleepiness questionnaire scores, such as the Epworth Sleepiness Scale, are often requested to assess the severity of the patient's sleepiness during the day.
It is also common for insurers to request clinical notes from the sleep apnea screening appointment. These notes should document symptoms, treatments, and outcomes related to sleep apnea, including high blood pressure, daytime sleepiness, cognitive or mood disorders, and heart disease. This information helps establish the medical necessity of the treatment.
In some cases, insurers may require evidence of CPAP (continuous positive airway pressure) refusal or intolerance. This may involve attempting CPAP therapy before approving oral devices, although it is becoming more common for insurance companies to cover oral devices without this prerequisite.
Lastly, it is important to note that state regulations may impact the process. Some states may have specific restrictions or requirements for dental practices ordering or providing sleep-testing devices to patients. Therefore, it is advisable to check the regulations in your state before proceeding.
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Medical insurance billing
Step 1: Understanding Coverage and Requirements
Before submitting a claim, it is essential to understand the patient's insurance coverage and the requirements of the insurance provider. Most medical plans offer coverage for custom-made oral appliances for sleep apnea. However, different insurers may have specific documentation and paperwork requirements. At a minimum, insurers typically require a copy of the sleep study, sleepiness questionnaire scores (such as the Epworth Sleepiness Scale), clinical notes from the sleep apnea screening appointment, and a CPAP refusal or intolerance affidavit. Some insurers may also request a copy of the physician's written order or prescription for the oral appliance and a signed "Proof of Delivery" form from the patient.
Step 2: Sleep Study and Diagnosis
A sleep study is usually required as part of the pre-authorization process. The gold standard for sleep studies is an in-lab polysomnogram (PSG), which involves the patient spending the night in a lab for comprehensive monitoring. However, insurers often accept the results of at-home sleep tests (HSTs), which are less intrusive and more convenient for patients. The diagnosis code for Obstructive Sleep Apnea (OSA) is ICD G47.33.
Step 3: Billing Codes and Preauthorization
To receive preapproval from the insurance company, you will need to provide the billing code for the custom sleep appliance, which is E0486. It is important to inquire about the insurance provider's preauthorization rules, as some may require preauthorization before delivering the oral appliance to the patient.
Step 4: Submit the Claim
Submit the claim to the patient's insurance company, providing all the necessary documentation and following their specific guidelines. This may include submitting evaluation and management codes, as well as cross-codes from dental to medical for radiographs or other procedures.
Step 5: Follow Up on Reimbursement
Work with the patient and the insurance company to ensure that reimbursement is processed correctly. This may involve coordinating with the Medicare Administrative Contractor (MAC) and understanding the claims processing information provided by CMS publications, such as Change Requests (CR) Transmittals and the Medicare Fee-For-Service Claims Processing Manual (CPM).
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Reimbursement expectations
The amount of reimbursement varies depending on the insurance provider, but it often ranges from 50-80% and can even reach 100% in some cases. It is important to note that there is also a possibility of no reimbursement coverage for oral appliance therapy, although this is rare. Medicare, for example, has specific stipulations regarding the type of appliances covered, the diagnosis level of the patient, and time restraints after the diagnosis is made.
To increase the likelihood of reimbursement, it is essential to submit the required documentation to the insurance carrier. This typically includes 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. Some insurers may also request a copy of the physician's written order (prescription for the oral appliance) and require the patient to sign a "Proof of Delivery" form. Additionally, it is beneficial to check with the insurance provider about pre-authorization rules and whether a home or laboratory sleep study is required for reimbursement.
It is worth noting that Medicare will pay for sleep apnea oral appliances, but only for those who are Medicare-enrolled providers. Practices can become licensed DME suppliers by submitting an application using the form CMS 855S. Once a facility becomes a DME supplier, all dentists practicing at that location are authorized for Medicare reimbursement.
Furthermore, it is important to manage expectations regarding reimbursement amounts. Some practices may set their expectations too high, aiming for $3,500 or more per treatment, which can price many patients out of treatment. The average insurance reimbursement is around $2,100, leaving the patient with a bill of at least $1,400, depending on their deductible. A more realistic and achievable goal for successful practices is a per-treatment profit of around $2,500, which will help make the treatment more affordable for a larger number of patients.
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Medical vs dental insurance
Medical and dental insurance plans differ in terms of coverage. While medical insurance is geared towards covering the cost of care when the unexpected happens, such as a trip to the emergency room, dental insurance focuses on preventive care to protect patients from developing painful and serious oral health issues.
Dental insurance typically covers 100% of the cost of preventive care, like check-ups and cleanings, with varying levels of coverage for other services, and an annual maximum benefit. This means that dental plans have an annual limit on payouts, after which the patient is responsible for all costs for the remainder of the year. Most dental insurance plans follow a 100-80-50 structure, covering 100% of preventive care, 80% of basic treatments, and 50% of more serious procedures.
Medical insurance, on the other hand, aims to protect policyholders from catastrophic expenses. In the event of a major illness, there is a set limit on how much the policyholder will have to pay out of pocket. Medical plans may also cover certain oral surgeries or trauma-related procedures, which creates some overlap with dental insurance.
When it comes to billing medical insurance for sleep apnea as a dentist, there are a few key steps to keep in mind. A sleep study is typically required as part of pre-authorization, with insurers accepting the results of at-home sleep tests (HSTs) that collect data on airflow, arousal, and blood oxygen levels. Additionally, detailed clinical notes and medical history are important for billing, and pre-authorization may be required for oral appliances. Medicare, for example, will pay for sleep apnea oral appliances, but only if certain conditions are met.
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Oral appliance therapy
Mandibular advancement devices (MADs) are the most frequently used oral appliances in the treatment of OSA. These devices are made of moulded hard plastic and snap over the upper and lower teeth, with metal hinges and screws that can be tightened to push the lower jaw forward. Two-piece MADs allow for more precise adjustments, tend to be more comfortable, and are often more successful in treating sleep apnea than one-piece oral appliances. Over-the-counter MADs, or "boil and bite" devices, are not usually recommended by sleep specialists as they do not fit properly and can be uncomfortable.
Most medical plans offer coverage for custom-made oral appliances. However, the documentation and paperwork required for insurance reimbursement may vary by insurer. Typically, insurers require 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. Many insurers also ask for a copy of the physician's written order (prescription for the oral appliance) and require that the patient sign a "Proof of Delivery" form.
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Frequently asked questions
The process of submitting a dental sleep device for medical insurance can be cumbersome and may vary depending on the insurer. However, the minimum required documents include a copy of the sleep study, sleepiness questionnaire scores, clinical notes from the sleep apnea screening, and a CPAP refusal or intolerance affidavit.
A sleep study can be done at home or in a lab. The gold standard of sleep studies is an in-lab polysomnogram (PSG) requiring a patient to spend the night in a lab. This test is comprehensive and monitored but may be inconvenient for the patient. Insurers also accept the results of at-home sleep tests (HSTs), which involve patients wearing minimally invasive devices during sleep to collect data on airflow, arousal, and blood-oxygen levels.
The ICD diagnosis code for Obstructive Sleep Apnea (OSA) in adults and pediatrics is G47.33. The billing code for the custom sleep appliance is E0486.
It is important to manage expectations and understand that reimbursement amounts vary depending on the insurance plan. On average, insurance pays around $2,100 per treatment, resulting in a bill of at least $1,400 for the patient, depending on their deductible. It is also beneficial to start small and gradually build relationships with local medical doctors to gain their trust and support for your dental sleep medicine program.
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