Frequently Asked Questions
Q: Do insurance companies cover oral appliance therapy?
A: Yes. Most medical insurance companies cover oral appliance therapy for treatment of Obstructive Sleep Apnea (OSA). In our office it is our experience that over 90% of the patients will have coverage for this treatment. However, insurance companies generally do not cover treatment for snoring only.
Q: Do most insurance companies have providers (dentists) in the network for OAT for sleep apnea?
A: No, most insurance companies do not have in-network providers for this treatment; however, the number is growing. Insurance companies are constantly looking for professionals to work at their discounted reimbursement fee schedules.
Q: How do I choose a dentist proficient in this procedure?
A: It depends on what you are looking for. First, educate yourself. This website is a good beginning. Also, check the Academy of Dental Sleep Medicine Website (www.DentalSleepMed.org). Standards of care vary widely as does training. Questions to ask your prospective provider are:
- What are the different appliance designs that you use? (Be sure your provider is proficient in both TRD (Tongue Retaining Device) and MRD (Mandibular Retaining Device) appliance types. Make sure trial procedures are used to determine the correct design for your condition.
- What is their educational and clinical background in oral appliance therapy?
- What is the nature of their follow-up?
Do your homework. Shopping for the right dentist is important.
Q: Can I still come to see Dr. Strauss and get coverage for my treatment even if he is not a provider in my insurance network?
A: In HMO’s, all referrals must go through your primary care physician. He/She must petition for an out-of-network referral justifying why it is necessary to allow this type of exception. PPO’s do not require authorization for referrals either in or out-of-network. If there are providers within the network, you can still see Dr. Strauss but you would receive out-of-network benefits.
Q: My insurance company requested a diagnostic code for my medical condition which is obstructive sleep apnea and code for this procedure (oral appliance therapy) for which I asked if I am covered. What are the codes they are referring to?
A: The diagnostic current code (referred to as the ICD code) for obstructive sleep apnea is 0327.23. The current, most commonly use treatment code (referred to here as CPT code) for an oral appliance used to treat obstructive sleep apnea is E0486. This is the differentiating code relating to coverage.
Q: How long does treatment take?
A: I generally break treatment into three phases. The first phase is diagnostic in nature and includes testing and evaluating the two basic types of devices. This phase can usually be completed within a four-week period.
Phase II involves making and fitting the custom appliance along with follow-up care. This usually takes two weeks.
Phase III is an ongoing evaluation and modification of appliances where required. We suggest patients should be seen every six months.
Q: Why don’t you take care of my insurance filing for me?
A: My focus is on providing professional care to the patient. I prefer my contract to be with the patient and not the insurance company. By not taking care of your insurance, I am able to give you more of my professional time without charging additional fees.
Q: How long does the appliance last?
A: Many appliances last several years or longer. Others have needed repairs within the first year. Things that impact this are: the choice of the appliance, the care given to the appliance, and the stress on the appliance from clinching and grinding. Trial procedures help to determine the best appliance design features for your situation, thus ensuing a more durable and longer-lasting appliance.
Q: Why do I need to pay for care at the time of the visit?
A: It is our practice to require payment at the time of service, and your insurance company will reimburse you according to your policy.
Q: Medicare is my primary provider. When Medicare denies coverage or even pays coverage I can submit the specific information to my secondary provider for reimbursement. How does Dr. Strauss’ non-participation in Medicare impact this?
A: To not participate in Medicare, doctors must “Opt-Out”. This means neither the patient nor doctor may submit a claim to Medicare. Therefore, no documentation of Medicare coverage or denial of coverage is available, if your secondary plan requires this. Medigap plans do not, and other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. Your supplemental may reimburse for coverage of treatment by doctors who have opted-out when you provide documentation of this with your signed copy of your opt-out form