Whether it is for your car, your home, or your health, insurance can be murky waters to wade through. This is especially true when it comes to obstructive sleep apnea (OSA). This is because when it comes to billing for the treatment for OSA, oral orthotics, it falls into a gray area somewhere between medical and dental healthcare providers.

Dental insurance or medical insurance?

Obstructive sleep apnea is a problem that is much more commonly addressed by dentists. However, it is actually considered to be a medical treatment to a medical disease. The trouble lies in the fact that most healthcare providers have contracts with insurance companies based on the type of service that they provide. Therefore, medical practitioners only get paid for providing medical provision, whereas dentists only get paid for administering dental treatments. So, while it would make sense for medical practitioners to bill their insurance for oral orthotics, most are not trained or accepted by the FDA to be able to supply the service.

In short, it is necessary for the dentist who administers and oversees your oral orthotics to bill your medical rather than dental insurance. This can be complicated for dental providers, so it would help if you can ensure that you are definitely covered before commencing with your treatment.

The ‘Oral Orthotics’ Clause

Many medical insurance policies have a clause which states that orthotic devices are not covered, and a good number of insurers will use this clause to argue that it applies to oral orthotics. However, in the majority of cases, when this clause was written it was in regard to the use of other orthotics such as artificial limbs, foot orthotics and other external detachable medical solutions.

If your insurer argues that oral orthotics are not covered by your policy, you should request a copy of their policy document for OSA to see if it specifically states that oral orthotics aren’t covered. If the document fails to mention their use, then you can argue that the policy doesn’t specifically exclude their use.

Am I Covered for OSA Treatment?

There are usually strict medical policy guidelines that define exactly what the insurer will pay for in terms of treatment for OSA. Many policies also contain specific conditions that should be met, even before any form of treatment is actually provided. For example, an insurer may insist that the patient demonstrates a certain number of episodes of apnea per hour or per night, particular symptoms or a combination of the above elements.

If you are looking to have your oral orthotic covered by your insurance, you should ensure that you have adequate coverage, before you commence with any treatment plan. Contact your insurer for a copy of their specific policy for obstructive sleep apnea treatment and check carefully that you meet their requirements.

Choose an in-network provider for your oral orthotics

Many policies require the holder to use an in-network provider for any treatment. An in-network provider is someone trained to provide oral orthotics on behalf of the network that your insurance company belongs to.
However, some insurance policies allow for a ‘network gap exception’, which is a tool used by insurers to compensate for gaps in their list of contracted providers. If your policy allows for network gap exception, or allows you to request one, you are asking your insurer to cover the care that you receive from an out-of-network provider at the higher, in-network rate. By choosing an in-network provider wherever possible, you can simplify the process of claiming from your insurance.

Medicare and Federal Employee Contracts

  • Medicare insurance will only pay contracted providers, and has a very precise medical policy for covering oral appliance therapy.
  • Their definition of what constitutes OSA is different and much more stringent than that used in commercial insurance companies.
  • The patient’s medical practitioner will need to provide a prescription that requests the dentist to supply an oral orthotic device.
  • Medicare will hold a deductible and co-insurance that will be the responsibility of the patient.
  • Many supplemental insurances will cover the deductible and co-insurance.

Federal Blue Cross Shield

Important information to understand about Federal Blue Cross Shield coverage includes:

  • This insurance does not prio-authorize DME coverage.
  • This insurance also does not pre-certify payment for oral orthotics.
  • Their basic plan does not cover oral appliance therapy.

Tricare: Dependents of the United States Armed Forces

Members of the Armed Forces and National Guard who are diagnosed with obstructive sleep apnea and treated with CPAP are not considered fit for deployment and as such many be released from the service.
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This insurance will:

  • Require a referral from your primary care physician.
  • Cover oral orthotics, but only if the patient is seen by a contracted provider.

The exact level of coverage will depend on the depth of your policy and should be checked before committing to your oral orthotics.

Want to know more about billing or financing your sleep apnea treatment at Bowie Dental Sleep Center? We will be gladly to help you find a practical and affordable approach to finance your treatment. Call us today to learn more at 301-464-4399.