Medical Insurance Reimbursement for Pediatric Airway Treatment

by Rose Nierman, CEO, Nierman Practice Management

There are exciting developments on the horizon! Medical insurers are beginning to consider oral appliances or functional orthopedic appliances medically necessary for pediatric patients with airway issues. Medical insurers are aware of the enormous costs of untreated Obstructive Sleep Apnea (OSA) in adults and children and are increasingly “getting their ducks in a row” by setting coverage criteria for pediatric airway issues.

Coverage Criteria and Required Documentation

What documentation supports the medical necessity for reimbursement? The answer is listed in the individual insurers’ coverage policy. When the policy does offer coverage, the dental practice’s documentation in the “medical model” format is essential for successful reimbursement.

Medical Policy Statements

Positive coverage statements for treatment of services such as adenoid-ectomy, tonsillectomy, and CPAP for pediatric airway are nothing new. However, an emerging trend shows policies considering payment for oral appliances in children as evidenced by the sample policy statement below.

Medically necessary
Dedicated pediatric forms

It’s widely known that the physical presentation of sleep breathing disorders (SBD) in pediatric patients differs from that of adults. With this in mind, Nierman Practice Management (NPM) has built dedicated pediatric questionnaire and exam forms to gather the documentation essential for pediatric reimbursement.

SOAP notes

The dental practice’s clinical documentation (SOAP notes) are vital to the insurance process. The subjective documentation includes chief complaints and other related history (e.g., snoring, mouth breathing, behavioral problems). The objective documentation consists of specific exam findings such as major anomalies of jaw size or anomalies of jaw-cranial base relationship (e.g., maxillary asymmetry, maxillary and mandibular hypoplasia or microgenia). The assessment section states both the pediatric patient’s diagnosis of OSA with applicable ICD-10 diagnosis codes for conditions such as major anomalies of jaw size or anomalies of the jaw to cranial base relationship. In the plan, describe the type of oral appliance and whether it is a custom or a prefabricated device.

Be an airway hero

Uncovering craniofacial anomalies and providing solutions for pediatric patients to improve airway function is extremely rewarding and has been proven to increase significantly the pediatric patient’s (and likely the parent’s as well!) quality of life through proper growth and development. With medical insurance reimbursement for these services now possible as well, we invite practices to become airway heroes for these patients and their parents.
For information on other medically necessary procedures for TMD and Sleep Apnea in the dental office, read Christine Taxin’s article, “Medical Management of Pediatric Sleep Apnea and TMD in Your Dental Office” here.

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