How to bill medical insurance for oral sleep appliances

How to bill medical insurance for oral sleep appliances?

Obstructive sleep apnea (OSA) is a sleep problem that, if left untreated, may be extremely dangerous to one’s health. Patients may visit your dental clinic in search of an oral appliance for treatment for a variety of this. Up to 50% of individuals can successfully treat their OSA using oral appliance therapy (Andrew Ng, H. Gotsopoulos, M. Ali, P. Cistulli, 2005). Oral appliances for disorders linked to sleep must be made and fitted by dentists. Dentists have to bill insurance for these appliances to get payment. Therefore, we will assist in telling you how to bill medical insurance for oral sleep appliances.

Why would patients prefer an OSA appliance over other options?

As oral appliances are the best therapeutic tool for sleep apnea, many patients find it suitable and comfortable to cope with their sleep apnea. According to a report, oral appliance therapy—the most popular alternative to CPAP—is preferred by 81% of patients (Jennifer Q. Le, Jeff L. Rodgers, Kevin Postol, 2018).

    • Oral devices have been shown to be effective, non-intrusive, and simple to use (Tahereh Hosseinzadeh Nik, 2011).
    • Easier to tolerate as compared to CPAP.
    • Less expensive and noise-free(Andrew Ng, H. Gotsopoulos, M. Ali, P. Cistulli, 2005).

Start billing medical insurance for oral appliances


A preauthorization initiated over the phone is frequently required for accurate medical billing for oral appliances, coupled with paperwork proving medical necessity. Besides using ICD and CPT diagnostic codes, a skilled insurance coordinator starts a benefit verification call. The patient is then informed about copayments and deductibles. Remember that oral appliances for OSA are not limited in any way throughout a lifetime. Some medical insurance companies may offer a new gadget after three or even five years. Providing proof of medical need is essential after the procedure has begun.

Understanding document

  • Diagnosis of sleep apnea by a board-certified specialist:

Patients with sleep apnea must first be diagnosed before receiving treatment. Only a board-certified sleep expert can confirm this diagnosis. The expert will score the sleep test findings and decide how severe the patient’s apnea is. Whether the sleep test was conducted in a lab or at home makes no difference. To diagnose and score this test, a process called interpretation is used. The board-certified sleep expert performs an interpretation, validates the diagnosis, and then documents the patient’s sleep apnea intensity and recommended treatments. Since diagnoses theoretically never expire, very few insurance companies place a time restriction or expiration date from the date of interpretation as long as it occurs before receiving treatment.

  • Copy of the sleep test results:

There are two kinds of sleep tests: a polysomnogram (PSG) and a home sleep test (HST). A copy of the sleep study supporting the diagnosis of OSA is required as supporting documentation for the medical need for some oral appliance therapy. The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) recommended that sleep doctors perform follow-up sleep testing to improve or validate the treatment’s effectiveness  (Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD., 2015). There are restrictions placed by certain insurance companies on the kinds of tests they will pay for. As an illustration, Medicare now demands that home sleep testing be utilized before PSG may be covered. Moreover, a particular AHI is advised by some payers for patients to be reimbursed for therapy. The patient’s AHI must thus be specified in detail in your sleep test reports.

  • Written order or prescription for an oral appliance written by a medical physician:

To treat the patient, you need a documented order or prescription from a medical professional because dentists are legally the ones who give the oral appliance or durable medical equipment. This might be from any doctor or medical professional the patient has visited. According to guidelines issued by the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM), patients experiencing symptoms of OSA must undergo a face-to-face examination by a sleep medicine physician for diagnosis purposes, and they prescribe oral appliances  (Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD., 2015) It frequently arrives in the form of a prescription and will have the procedure code listed on it. The diagnostic code should also be included.

  • CPAP affidavit:

A signed affidavit declaring that the patient declined CPAP or is hypersensitive to CPAP is required by some insurers. People who do not respond positively to CPAP, who fail therapy with CPAP, or those who are not suitable for CPAP are likely to gain dental/oral appliance therapy (Kushida C.A., Littner M.R., Hirshkowitz M., Morgenthaler T.I., Alessi C.A., Bailey D., Boehlecke B., Brown T.M., Coleman J., Friedman L., et al., 2006). It’s critical to find out what paperwork the insurer wants and needs. The affidavit only indicates that both treatment alternatives have been presented to them, and they have decided to use an oral appliance for whatever justification they may offer. Participants will put their signatures on the affidavit and provide information about why they think a CPAP will not benefit them.

  • The dentist’s clinical chart notes:

The topic of SOAP (Subjective, Objective, Assessment, Plan) notes might make workplaces anxious or frustrated. On a SOAP note, all that you will do is:

    1. Outlining the patient’s symptoms
    2. Writing the diagnostic data, you have gathered (which includes the sleep test and its intensity evaluation)
    3. Telling the recommended course of therapy.

Whenever you give the appliance, you should make notes regarding the patient’s convenience, how to use it at home, and the position you chose for the adjustment.

Medical exams code

For mouth OSA screening and follow-up sessions like a six-month or yearly inspection of the appliance, medical codes for examinations called Evaluation and Management codes may be filed. The exam codes for medical insurance are the same as those for dental insurance. To justify the level of the code invoiced, whether a quick checkup or a more thorough encounter, the practice must record the medical history taking and exam elements when charging these “office visit” codes. It is said that Medicare will only pay for oral appliances that have suffered coding verification review by the PDAC Contractor.

MedsDental billing company is ready to bill your medical insurance for sleep appliances

To maintain compliance with the laws and obtain payment for oral equipment, dentists must keep a keen eye on any legal changes that impact the accessibility of these appliances. It might be difficult for a dentist to keep up with the advancements in the insurance company’s policies and documentation requirements because they constantly change. MedsDental Dental Billing Company will be a trustworthy partner for you by professionally handling your billing.

Outsource with us without any onboarding charges and enjoy the perks of our experienced team, who remains updated with the constantly changing rules of insurers and bill accordingly for oral appliances using reliable software. Furthermore, your oral device will be coded accurately and quickly by our qualified billers, who are experts in the efficient billing procedure. We adhere to HIPAA regulations and deploy HIPAA-compliant services since protecting patient information and records is required, helping your clinic escape fines.

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