FDA Registered, Prefabricated, Custom Fitted Oral Appliance
Most Insurer Medical Policies now recognize Oral Appliance Therapy as a medically necessary option for patients with documented Mild to Moderate Obstructive Sleep Apnea. Many also consider it a valid conjunctive therapy for use with CPAP, or as additional therapy for Surgical Intervention that results in residual OSA. Each policy varies and is subject to the plan and benefit limitations in effect at the time that the service is provided, and therefore it is highly recommended to precertify Oral Appliance Therapy prior to providing the service to ensure coverage and limitations.
Only FDA Registered Devices (Prescription) are considered Medically Necessary and some plans only cover Custom Made, custom fitted devices and some require fitting by dental personnel.
The two predominant codes recognized by Insurers (REFERENCE ONLY 1) for the SomnoGuard line of devices are:
E0485 Oral Device/Appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and Adjustment.
CPT 21085 Impression and custom preparation; Oral Surgical Splint, Maxillofacial Prosthesis code, coverage subject to specific plan inclusion, precertification recommended
ONLY REFERENCE ONE CODE as recognized as medically necessary by individual insurers.
Only FDA Registered Devices (Prescription) are considered Medically Necessary and some plans only cover Custom Made, custom fitted devices and some require fitting by dental personnel.
The two predominant codes recognized by Insurers (REFERENCE ONLY 1) for the SomnoGuard line of devices are:
E0485 Oral Device/Appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and Adjustment.
CPT 21085 Impression and custom preparation; Oral Surgical Splint, Maxillofacial Prosthesis code, coverage subject to specific plan inclusion, precertification recommended
ONLY REFERENCE ONE CODE as recognized as medically necessary by individual insurers.
Recognized by most Medical Policies for OSA
Effective and affordable solution for Snoring as a patient pay service
Most Major Insurer Medical Policies recognize Oral Appliance Therapy (OAT) as a Medically Necessary treatment alternative for patients positively diagnoses with Mild to Moderate OSA, many as a first line treatment option as opposed to CPAP. Several Medical Policies are linked in the right sidebar.
Typical indications and Medical Policy language include:
The treatment of OSA in adults is considered medically necessary for individuals who meet either of the following criteria:
Note: For the purposes of this document, the terms apnea hypopnea index (AHI) and respiratory disturbance index (RDI) are interchangeable, although they may differ slightly in clinical use; an AHI/RDI greater than 30 is consistent with severe obstructive sleep apnea. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.
The following non-surgical treatment in adults is considered medically necessary: Oral Appliances:
Custom-fitted and prefabricated oral appliances are considered medically necessary for persons with OSA who meet the above medical necessity criteria.
Documenting Specific Insurer Medical Policy and plan criteria is supported by our Administrative Assistance document.
Typical indications and Medical Policy language include:
The treatment of OSA in adults is considered medically necessary for individuals who meet either of the following criteria:
- Apnea Hypopnea Index (AHI) or a Respiratory Disturbance Index (RDI) greater than or equal to 15 events per hour;
- AHI (or RDI) greater than or equal to 5, and less than 15 events per hour with documentation demonstrating any of the following symptoms:
- Excessive daytime sleepiness, as documented by either a score of greater than 10 on the Epworth Sleepiness scale or inappropriate daytime napping, (e.g., during driving, conversation or eating) or sleepiness that interferes with daily activities; or
- Impaired cognition or mood disorders; or
- Hypertension; or
- Ischemic heart disease or history of stroke; or
- Cardiac arrhythmias, or
- Pulmonary hypertension.
Note: For the purposes of this document, the terms apnea hypopnea index (AHI) and respiratory disturbance index (RDI) are interchangeable, although they may differ slightly in clinical use; an AHI/RDI greater than 30 is consistent with severe obstructive sleep apnea. In some cases, respiratory effort-related arousals (or RERAS) are included in the RDI value. These RERA episodes represent EEG arousals associated with increased respiratory efforts but do not qualify as apneic or hypopneic episodes because of the absence of their defining air flow changes and/or levels of oxygen desaturation.
The following non-surgical treatment in adults is considered medically necessary: Oral Appliances:
Custom-fitted and prefabricated oral appliances are considered medically necessary for persons with OSA who meet the above medical necessity criteria.
Documenting Specific Insurer Medical Policy and plan criteria is supported by our Administrative Assistance document.
