Diagnosis with polysomnography (a sleep test) is required and must be reviewed by a physician. To limit the number of patients who qualify for an oral device, insurance companies often require the severity of the sleep apnea to be a moderate-severe level (>15 breathing events per hour). Most medical insurers are likely to cover the sleep test. These details can be provided by your sleep testing facility.
Patients with mild sleep apnea (5-15 breathing events per hour) do not automatically qualify for treatment of their sleep disordered breathing, unless they also have an additional diagnosis of hypertension, heart attack, stroke, mood alteration (depression), impaired cognition (memory loss), insomnia or excessive daytime sleepiness. Each company has guidelines as to how each of these additional diagnoses must be verified prior to approval of treatment. By submitting a “pre-determination or pre-certification” request with the insurance company, we usually get a statement approving or denying the potential services prior to their completion.
Insurance companies generally will not pay for an oral device that is to be used for the convenience of the patient. This would include a patient who uses CPAP at home but wants an oral device to use when traveling, hiking or camping. The exception to this rule is with Tricare; as active duty military personnel do not always have electricity to run their CPAP machine.