Oral appliance therapy is not only a lifesaver but can also save relationships. Hence many dental offices find it highly rewarding to help patients manage obstructive sleep apnea (OSA). Most medical plans offer coverage for custom-made oral appliances, and it’s helpful to prepare for insurance requests for paperwork. The following Q & A provides answers to the most common questions I receive about medical insurance reimbursement for oral appliances.
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What documentation do insurance companies require for oral appliances?
Documentation and paperwork can vary by the insurer, but the minimum is 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 of the insurers are asking for a copy of the physician written order (prescription for the oral appliance) and require that you have the patient sign a “Proof of Delivery” form. Also, include medical history details that were noted such as high blood pressure or other comorbidities.
How can I predetermine if medical insurance covers an oral appliance?
Start by making a call to the eligibility & 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. Most health insurance plans categorize oral appliances for OSA as medical equipment, so reimbursement is typically under the coverage for Durable Medical Equipment (DME). DME is the benefit category for medical equipment such as electrical stimulators for pain, wheelchairs & walkers. The information to receive during the benefit verification:
- Deductible amount
- How much of the yearly deductible has been met
- Copayment amounts or percentages
- Preauthorization requirements
- Is a Medicare-approved oral appliance necessary (ask this of commercial carriers since some require a Medicare-approved appliance)?
- Is a “GAP exception” allowed for out of network providers (to lower the out of pocket costs for the patient)?
What are the billing codes?
Currently, there is only one medical diagnosis code available for OSA, so if the patient has this condition, the diagnosis code on the sleep study will be ICD diagnosis code G47.33, which stands for Obstructive Sleep Apnea (adult) (pediatric). To receive preapproval, 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
There is a good possibility that the oral appliance will need to be preauthorized in advance, so be sure to inquire about preauthorization rules. If a preauthorization is required, it’s important to wait for 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 and even some commercial insurers specify that an oral appliance must be on Medicare’s published Product List to be covered.
Will medical insurance tell me how much they cover for a mouthpiece or appliance?
The insurance representative may not be able to determine the exact dollar amount of reimbursement in advance, but they will be able to tell you if they offer the benefit as part of the plan.
What about deductibles. Are they as high as for other procedures?
The deductible can differ from the yearly deductible for other services since most carriers categorize oral appliances for OSA as Durable Medical Equipment (DME). Equipment such as oral appliances and CPAP may carry a separate or different deductible from the usual one. That is why it’s important to make sure that you check the policy for DME benefits.
Does insurance cover snoring mouthpieces?
It is important to know that while most medical insurers do offer coverage for oral appliances with a diagnosis of OSA, snoring alone is not a covered benefit. Custom mouthpieces for OSA may be considered “medically necessary” for mild to moderate OSA. Also, oral appliances are generally covered for severe OSA if the patient cannot tolerate CPAP or in some cases if the patient refuses CPAP.
Does Medicare offer coverage for sleep apnea oral appliances?
Medicare, the program for seniors and people with certain disabilities, does provide coverage for custom oral appliances for OSA and covers specific oral appliances. For a dentist to receive reimbursement from Medicare or to bill Medicare for an oral appliance for sleep apnea, the treating dentist must enroll their practice location as a Medicare DME Supplier. An application can be submitted to become a licensed DME supplier using the form CMS 855S. Once a facility becomes a DME supplier, all dentists practicing in that location are authorized for Medicare reimbursement. We get many questions about DME supplier credentialing. For those practices who are wanting to simplify the process, contact Maura Lovett at 561-575-0737 ext. 1001.
Can we get reimbursed for our sleep screening exam? We would also like to bill for a panorex and possibly a cephalometric radiographic view?
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 had an exam three months ago and you need to do another, the insurance typically will reimburse for both.
Can we bill follow-up visits for adjustments to the oral appliance?
Yes, you can bill commercial carriers, using a medical office visit code, for the adjustments to the oral appliance. Most carriers bundle the first 90 days of adjustments into the code for the custom appliance (E0486).
With the right tools to navigate medical insurance billing, you can help more of your patients receive the care they need – saving lives and relationships. Your patients will thank you!