Because sleep apnea is considered to be a serious medical condition, treatment—including oral appliance therapy—is covered by many medical insurance programs. Dr. Goldberg’s office is a “fee for service” practice, and does work with many insurance companies. We can provide you with assistance and the appropriate documentation needed to help obtain eligible coverage for your oral appliance therapy, and will be happy to submit your claim to your medical carrier.
The specific benefits available for your therapy will depend on the nature of your medical insurance policy, and it is recommended that you contact your insurer to determine available coverage and seek pre-authorization of benefits, if possible. When contacting your insurance provider to determine your eligibility for coverage, it will expedite the process if you are able to provide the account representative with certain specific codes that relate to treatment: Diagnosis Code 327.23 for the treatment of obstructive sleep apnea, and CPT/HCPCS Code E 0486 for the use of a custom oral appliance.
Insurance providers who are less familiar with oral appliance therapy may question why treatment will be provided by a dentist rather than a physician. This issue can best be resolved using your sleep study as proof of a diagnosis of obstructive sleep apnea; which is considered to be a medically necessary condition. And in some cases, proof of prior intolerance to CPAP therapy may be required. If coverage is initially disputed, you may wish to ask to involve a claims supervisor, and to request confirmation of the specific exclusion from your policy stating that the benefit is excluded. A copy of the explanation of benefits from your contract will verify specific policies, exclusions, and limitations of your medical insurance contract.
If coverage for oral appliance therapy is pre-authorized, you will receive a claim number, which our office can then use for processing the claim. Throughout the claims process, we maintain contact with the insurance company to determine the status of your claim.
If you receive an initial notification of denial of benefits, you have the right to appeal. The best way to initiate a review is by sending a certified letter to the insurance company, which will be forwarded to the appropriate dispute resolution offices. We will do our best to process the claim but may ask for our patients participation in some instances.