Frequently Asked Questions about Insurance Coverage for Oral Appliance Therapy

 

Q: Is treatment covered by my dental insurance or medical insurance?

A: Since obstructive sleep apnea is a medical condition, treatment is covered by your medical insurance. Pittsburgh Dental Sleep Medicine dentists are in-network with most medical insurance plans.

Q: Can I use my dental insurance to cover the cost or an oral appliance?

A: No, since obstructive sleep apnea is a medical condition it is covered by medical insurance not dental insurance.

Q: Does medical insurance cover the cost of an oral appliance?

A: Yes, in most all cases medical insurance will cover the cost of your appliance.  Your out of pocket payment would include any deductible, coinsurance or copays your plan may require for treatment.  We will explain your benefits to you and any out of pocket costs you may have before we begin treatment.

Oral appliance therapy is now a widely accepted treatment for obstructive sleep apnea.  There are very few medical insurance companies that do not cover this treatment.  

We are an in-network provider with most all insurance companies.  Some of the insurance companies we have contracts with are Blue Cross Blue Shield, UPMC Health Plan, United Health Care, Aetna, Cigna, TriCare, Medicare and Medicare Advantage Plans.  We work closely with many other insurance companies so that you receive the highest level benefits for treatment reducing your out of pocket costs. 

NOTE: Some Medicaid plans cover oral appliance treatment such as Gateway Health Plan but some others do not cover treatment.

Q: What will my out of pocket costs be?

A: Your out of pocket costs will vary depending on your specific insurance plan. Out of pocket costs are your deductible, coinsurance and copays. We will check your benefits for you and will find out what your deductible is and if you have met any of it for the year. We will also check to see what your coinsurance is (it is a percentage). Depending on your insurance plan your plan may pay anywhere from 100%, 90%, 80% or 50% of their allowed amount for treatment. Some plans will require a copay (the amount that you pay for specialist office visits).
Our highly trained staff will work with you to maximize your medical insurance benefits.

Q: Does my medical insurance cover oral appliances for snoring only?

A: No, medical insurance will only pay for an oral appliance if you have been diagnosed with obstructive sleep apnea. A diagnosis of sleep apnea is made by a physician after reviewing the results of your sleep test.

Q: Do I need a referral from my physician?

A: We will need to obtain an order for the oral appliance from your physician. We will work closely with your physician to get the appropriate medical documentation required by your insurance company.

Q: Does Medicare cover oral appliance therapy?

A: Yes, Medicare does cover treatment and we must meet all Medicare medical documentation requirements before we can begin treatment. Our highly trained staff will work with you and your physician to make sure we have all the proper medical documentation.

Q: How do I get a sleep test?

A: You will need to see a physician. Any physician (MD or DO) can order a sleep test for you.

The results will be sent to your physician. Most insurance companies will allow you to receive an oral appliance as a first line treatment for mild to moderate sleep apnea. This means that you do not need to try a CPAP or BiPAP mask and machine first. If you are diagnosed with severe sleep apnea, most insurance companies will require that your try CPAP first. If you cannot tolerate CPAP or BiPAP, or are claustrophobic to using a face mask you will be able to be treated with an oral appliance.

Q: What if I do not want to go to a sleep lab for a sleep test?

A: No problem! Most insurance companies now pay for a home sleep test. This is a simple testing machine that you can use to diagnose sleep apnea while sleeping in your own bed!

Q: I have full dentures. Can I have an oral appliance?

A: Unfortunately, no. You need most of your teeth in tact in order to use an oral appliance.

Q: My dentist told me I need extensive dental work. Can I still get an oral appliance?

A: If you need extensive dental work such as crowns and or bridges we would want you to complete your dental work before we could begin oral appliance therapy.

Q: Do I have to try CPAP or BiPAP before my insurance plan will pay for treatment?

A: Some insurance plans require that you try CPAP or BiPAP treatment first before they will pay for an oral appliance. Medicare and some other plans DO NOT have this requirement. Our staff will check your insurance plan for you to see if they require that you try CPAP or BiPAP before you make an appointment with us.

Q: I use my CPAP machine most nights at home but I would like to have an oral appliance for when I travel.  Will my medical insurance cover an oral appliance for travel so I don’t have to take my CPAP machine with me?

A: Unfortunately, if you are successfully using your CPAP or BiPAP machine your medical insurance will not cover an oral appliance for travel.  If you want an oral appliance just for travel you would have to pay for it yourself.

Q: I have used CPAP for a while but I cannot stand to use it any more.  Can I get an oral appliance and will my insurance pay for it if they already paid for a CPAP machine?

A: Yes. We will need to get documentation from your physician that you are not tolerating or have discontinued using CPAP or BiPAP and a signed order from your physician before we can provide you with an oral appliance for sleep apnea.