Insurance Coverage for Oral Appliance
(orthotic) Treatment

COMMERCIAL INSURERS:

Oral appliances (orthotics) are considered a medical treatment for a medical disease; dental insurance will not cover this procedure. This arrangement makes it difficult for dentists to bill for the appliance (orthotic) and requires significant effort on the part of the dental office staff. Dentists often have contracts with insurance companies as “dental providers” who are paid only for dental procedures. Physicians have contracts with insurance companies as “medical providers” and are NOT trained in the fabrication of oral appliances (orthotic) accepted by the FDA for the treatment of obstructive sleep apnea.

Most medical insurers in the US have “Medical Policy Guidelines” that spell out what they will pay for as an insurer and what they consider ‘experimental’ and, therefore, will not pay for. They also set forth the guidelines a patient must meet before treatment will be covered. An example is a person who is diagnosed with “upper airway resistance syndrome” a level of sleep disordered breathing just below mild sleep apnea. Most insurers have guidelines that read “the patient must have more than 5 breathing events per hour AND two symptoms such as daytime sleepiness, high blood pressure, heart failure or stroke. Or: The patient must have 15 breathing events per hour if there are no other symptoms before coverage for treatment is allowed”. Each insurance policy holder has the right to contact his/her medical insurer and obtain a copy of the Medical Policy Guidelines for the treatment of obstructive sleep apnea.

Be aware that some insurance companies have made policy that declares oral appliance (orthotic) therapy to be “experimental’ and do not cover any appliances (orthotics). This view is severely out of date and is something I consider to be a disservice to their members. The last insurance company I found that still had these out dated rules was Blue Cross Blue Shield of Alabama. Each patient might want to contact the medical insurance company by whom they are insured.

How does a patient find out if oral appliances (orthotics) are a covered service?
1. Get a copy of the medical insurers “Medical Policy Guidelines on the treatment of obstructive sleep apnea.
2. Call the members services department and find out if the policy covers ‘durable medical equipment’ (DME). This includes the part of insurance that covers items you can buy for medical care: crutches, sugar monitors, wheelchairs, etc. It is best to know that the most common billing code used by insurance companies for oral appliances (orthotic) is E0486. Ask the representative if the code E0486 is payable under the contracted policy.
3. You must also find out what percentage they pay to “out-of-network” providers (the patient pays the balance)
4. Is there an annual deductible? (An amount the patient must pay before the insurance company pays anything at all)
5. Is there an annual maximum? (Some policies only have a $1500 annual limit. This means that if the patient has used part of the money set aside for DME purchases such as a CPAP machine, then there may be very little money leftover that year to pay for an oral appliance (orthotic). This means that the patient pays more of the dentist’s fee.
What stumbling blocks does the medical insurance company, who covers oral appliances (orthotics), put in the way of the patient receiving care from a dentist?

The Medical Policy Guidelines of most medical insurance companies require that every patient diagnosed with obstructive sleep apnea use CPAP as their first mode of therapy. The guidelines allow surgery or oral appliances (orthotic) ONLY if the patient is intolerant of CPAP. This is based on the guidelines issued by the American Academy of Sleep Medicine where physicians have proven that CPAP is the most reliable, most effective, and creates the best improvement in all the medical problems created by sleep apnea. All other treatments are considered “second best”.

How can a patient maximize insurance coverage?

1. Ask the members service representative if the policy allows: “Network Gap Exception” or “Network Insufficiency”. These terms mean that, even though the insurance contract states that a patient must see in in-network (contracted with the insurance company) provider to obtain maximum coverage, if the insurance company does not have a provider contracted to them, or “in-net”, who is trained to do oral appliances (orthotic), then the insurance company must pay any provider at the higher in net-work rates. Some policies, often HMOs, will not allow “Gap Exception” Some PPO policies have two different tiers of payment; one for in-net providers and one for out-of-net providers. Some of these PPO policies allow for network gap, others do not.
2. Some state insurance laws preempt insurance company policy and mandate “Gap Exception”. The state office on insurance may be of some assistance.
3. Be aware that most medical insurance companies do not know what an oral appliance (orthotic) is. Some policies state that there is no coverage for “oral (orthotic) devices”. The representative will then say that oral appliances (orthotics) are not a covered service. When these policies were written, this statement referred to foot appliances (orthotic) (from a podiatrist), artificial limbs and other, external detachable mechanisms. It is important that you ask to receive a copy of the Medical Policy for obstructive sleep apnea. If that portion of the contract says that ‘oral appliances (orthotics)’, specifically, are not covered (excluded), then there will be no coverage from the medical insurer. If there is no mention of oral appliances (orthotic) under the medical policy guidelines for the treatment of obstructive sleep apnea, the patient can make an argument that the policy does not really exclude coverage. The patient should ask again if the code E0486 is a covered service.

Note: The DME provider, Northwoods, for General Motors and other auto makers, claims that oral appliances (orthotics) are not a covered service under the employee’s contract. They refuse to furnish providers and contracted members with a copy of the “Medical Policy Guidelines” for treatment of obstructive sleep apnea and will furnish no written proof that their denial of coverage is actually written in the contract. Northwoods claims they are not bound by state law which says that insurance companies have to provide members with written policy statements when requested. They say that under “ERISA” laws (federal guidelines) they do not have to provide this information. A patient insured through a policy with the automakers may wish to go to their human resources representative or union representative and verify that Northlands has the legal right to do this.

What about the initial evaluation by the dentist?

In my office, I attempt to pre-certify all new patients if I have the correct information. I require the patient’s: address, date of birth, a legible copy of both sides of the medical insurance card with all appropriate telephone numbers. I call the Precertification number and ask how I can apply for authorization to see the patient for an evaluation and receive payment at in-network (higher) rates. Often the insurance company will ask for copies of the sleep studies (polysomnograms) and a letter of ‘medical necessity’ from the referring physician. They also want a letter from my office explaining the billing codes I intend to use, what the fees are for each code, and expected dates of service. Some insurance companies allow these requests to be faxed to them, some require that the documentation be mailed in (it is then, often ‘lost’ at the insurance company), others may be more liberal and grant Precertification over the phone.

Federal Blue Cross Blue Shield:

1. Does not prior authorize DME coverage.
2. They will do 'preservice review' is all necessary
information is mailed to the appropriate address.

May cover less than 0-50% of the costs.

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

AVALABLE OFFICE HOURS:

9:00 t o 5:00 (Mon)
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12:00 to5:00 (Sun)
CALL 617.964.4028
in Massachusetts
317.842.9866
in Indiana

 

The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/