Is a Mandibular Advancement Device (MAD) Covered By Insurance? Understanding Sleep Apnea Oral Device Coverage | Daybreak

Sleep apnea is a serious sleep disorder that affects millions of people worldwide. It occurs when the airway is partially or completely blocked during sleep, causing breathing and sleep pattern disruptions. It can increase the risk of heart disease, stroke, depression & anxiety, and sufferers often report experiencing daytime sleepiness, morning headaches, and general fatigue.

Oral appliance therapy is a common treatment option for mild to moderate sleep apnea and is increasingly used as a solution for severe sleep apnea as well.

It involves wearing a custom-made oral appliance, similar to a sports mouth guard or orthodontic retainer, that gently moves the lower jaw to a forward position in order to keep the airway open during sleep. Dental appliance therapy is a non-invasive and non-surgical treatment option that can effectively improve sleep quality and reduce symptoms of sleep apnea.

Most insurance companies do cover oral appliance therapy, but as always with insurance, the devil is in the details. This article will attempt to answer the most frequent questions about health insurance coverage, but to see whether your specific health insurance plan covers oral appliances, you can use the Daybreak Insurance Check here.

The first step to obtaining a dental sleep appliance and receive health insurance reimbursement is to obtain a clinical diagnosis of sleep apnea from a doctor (note that the diagnosis must be from a medical physician, not a dentist). Insurance companies will always require that this diagnosis be based on a valid sleep test, either from a lab study such as a polysomnogram (PSG) or a home sleep study such as the one provided by Daybreak. Generally, insurance companies require the sleep test to be no older than one year.

During the initial consultation, the physician will review your medical history and lab or home sleep study results to diagnose whether you have clinical sleep apnea and, if so, whether it is mild, moderate, or severe. Severity is based on AHI (Apnea Hypopnea Index), a measurement of the rate of apnea or hypopnea events (as measured by drops in blood oxygen saturation) per hour of sleep.

Once you have been diagnosed with sleep apnea, your sleep doctor or dentist needs to write a prescription for a custom-made oral appliance.

One important distinction is that although mandibular advancement devices (MADs) for obstructive sleep apnea (OSA) are oral devices and often provided by a dentist, they are not covered by dental insurance. And although a dentist can bill health insurance, most dentists do not have in-network relationships because it is rare for them to have procedures for which they can regularly bill (sleep dentists are a notable exception).

Generally speaking, a sleep apnea dental device can be provided and billed to health insurance by a physician, a dentist, or a durable medical equipment provider.

Once you have a valid diagnosis and accompanying prescription, the next most important determinant of coverage is diagnosed severity.

Does insurance cover an oral device for Mild Sleep Apnea?

Although every insurance company is different, and even among a given insurance company different plans can have varying requirements, most health insurance plans will cover an oral device for someone suffering from mild sleep apnea if they have co-morbidity.

This co-morbidity could typically be any of the following: heart disease, hypertension, a history of stroke, mood disorders, or excessive daytime sleepiness as measured by the Epworth scale.

Is an oral device covered by insurance for Moderate Sleep Apnea?

Again, while every insurance company is a unique snowflake, generally speaking, most medical insurance plans cover oral appliances to treat moderate obstructive sleep apnea without any additional requirements.

Is an oral device covered by insurance for Severe Sleep Apnea?

Significant variation exists for dental appliance insurance coverage for treating severe sleep apnea, but most insurance companies will do so if there is documentation that the patient has "failed" CPAP therapy.

A patient has "failed" CPAP therapy if they have already been prescribed a CPAP machine for treating their sleep apnea, but were unable to use the device routinely. A typical reason for discontinuing CPAP therapy is discomfort.
Most medical insurers will also accept a physician deeming a patient "contraindicated" (in other words, not an appropriate candidate) for CPAP therapy, although this is a fairly rare instance and reserved for cases such as patients suffering from condition such as PTSD or severe claustrophobia, or exhibiting facial deformities that would not allow a CPAP mask to successfully seal.

Additionally, some medical insurance companies will also reimburse oral appliances for patients who "refuse" CPAP therapy.

While most medical insurance plans cover oral appliances for sleep apnea if you meet the required criteria, your plan’s features will determine if it is fully covered, or if you will cover a portion out-of-pocket.

For example, the amount remaining on your deductible and what percentage of the cost your plan says you’re responsible for versus what your insurer will cover (coinsurance) can apply. Some insurance plans require a pre-authorization request before approving coverage, which are typically submitted by your provider on your behalf. Also important is whether your doctor is in-network.

If you'd like to learn more about the specifics of your health insurance plan and its coverage of dental appliance therapy for treating clinical obstructive sleep apnea, check your insurance coverage with Daybreak here

At Daybreak, we simplify the process by offering:

• Fully at-home sleep testing to diagnose OSA.
• Custom-made mandibular advancement devices for patients who qualify.
• Assistance with medical insurance to help you navigate coverage requirements. Patients should reach out to their insurance providers to inquire about coverage for sleep apnea treatments.

If you’re struggling with sleep apnea or snoring, our FDA-cleared solutions are effective, convenient, and backed by medical expertise.

Sleep apnea is treatable, and with the right information and support, accessing your insurance benefits for a MAD can be straightforward. Contact Daybreak today to learn more about our testing and treatment options and how we work with your insurance to provide the care you need.

Are non-custom, "boil and bite" oral devices covered by insurance?

Most medical insurers only offer coverage for custom-made oral devices, although a few do offer coverage for non-custom made "boil and bite" or "prefabricated" appliances.

How often will my insurance company pay to replace my oral device?

It varies by company, but most will pay for a new replacement device every 3-5 years.

Will my dental insurance cover my oral appliance therapy?

No, dental insurance does not cover oral appliance therapy. Delta Denta does not, Metlife Dental does not, and Aetna Dental does not.

Will my health insurance cover snoring?

In almost all cases, the answer is no. Although snoring is a typical symptom of sleep apnea, without a clinical sleep apnea diagnosis provided by a physician and derived from a sleep test, treatment for snoring is typically not covered as a medical necessity by health insurance plans. There is one exception to mention, currently Independence Blue Cross does indicate coverage for custom-made oral devices for a diagnosis of primary snoring - as long as "behavioral measures" such as weight loss for overweight individuals, sleep positioning, and refraining from alcohol and other sedatives has been tried & failed.

Does Aetna cover oral appliances to treat sleep apnea?

Yes, Aetna does cover oral devices (MADs), assuming their required criteria are met.

Does UnitedHealthcare (UHC) cover oral appliances to treat sleep apnea?

Yes, UnitedHealthcare (UHC) does cover oral devices (MADs), assuming their required criteria are met.

Does Cigna cover oral appliances to treat sleep apnea?

Yes, Cigna does cover oral devices (MADs), assuming their required criteria are met.

Does Humana cover oral appliances to treat sleep apnea?

Yes, Humana does cover oral devices (MADs), assuming their required criteria are met.

Do Blue Cross or Blue Shield cover oral appliances to treat sleep apnea?

Yes, Blue Cross and Blue Shield do cover oral devices (MADs), assuming their required criteria are met.

Does Oscar cover oral appliances to treat sleep apnea?

Yes, Oscar does cover oral devices (MADs), assuming their required criteria are met.

Does Medicare cover oral appliances to treat sleep apnea?

Yes, Medicare covers oral devices (MADs), assuming the required criteria are met. However, unlike most commercial payors, the oral device must be billed for by a dentist.