Dentists have been providing sleep apnea treatment with dental appliances since the late 1980s. Glidewell has been helping these clinicians facilitate treatment since 1996, with the introduction of the Silent Nite^® Sleep Appliance. Since that time, the laboratory has provided dentists with over 400,000 sleep devices from its family of patient-specific appliances, achieving excellent results.

A persistent challenge for dentists, however, has been reimbursement for sleep apnea treatment. Insurance reimbursement for the delivery of a sleep apnea appliance has required dentists to register as care providers with medical insurance companies, so that they can bill sleep apnea therapy with current procedural terminology (CPT) codes. CPT codes are a list of standardized procedure codes established and maintained by the American Medical Association (AMA).

In April 2021, the American Dental Association (ADA) approved adoption of current dental terminology (CDT) codes, and the organization has announced that as of Jan. 1, 2022, dental codes for the treatment of sleep apnea will be available for dentists to use for patients with a physician’s diagnosis. These codes fill a void in the current dental code set, and are expected to make the documentation and reporting of these treatments within dentistry much easier.

Although it remains to be seen what, if any, effect the terminology and reporting codes will have on current medical reimbursement or possible dental insurance reimbursement for these procedures, this is an important issue in sleep dentistry. As such, this article will briefly describe the new CDT codes for sleep apnea appliances. In addition, it will include a discussion of the impact of customized dental devices on patients, and provide an overview of how medical reimbursement works today.

The book “CTD 2022: Current Dental Terminology” includes new codes for pre-visit patient screening; fabricating, adjusting and repairing sleep apnea appliances; and removal of temporary anchorage devices. Codes are as follows:

• D9947 — Custom sleep appliance fabrication and placement
• D9948 — Adjustment of custom sleep apnea appliance
• D9949 — Repair of custom sleep appliance

Snoring and sleep apnea are breathing disorders of the upper airway that have similar etiology. The health implications of the two conditions can be very different. It is important to understand the effect of the upper airway on respiration during sleep.

As a patient falls asleep, the muscles, ligaments and tissues of the airway relax, and the tongue falls into the back of the throat, causing a partial airway obstruction. As air rushes over the relaxed tissues, they vibrate, creating the snoring sound. This collapse is made much worse if patients sleep on their back, or if they’ve consumed alcohol or eaten a large meal.

In its simplest form, snoring is a benign issue that may cause bed partner disturbance. However, snoring can lead to potentially serious health implications. The partial airway collapse and restriction of airflow could result in upper airway resistance syndrome, a condition that, if prolonged, may result in daytime sleepiness and a 42% increased risk of developing high blood pressure, even if all other symptoms appear normal.

If the airway is subject to a total collapse, sleep apnea has occurred. Sleep apnea is a condition that is associated with diabetes, hypertension, coronary artery disease, myocardial infarction, congestive heart failure and stroke.

To the untrained ear, these conditions are almost indistinguishable from each other. While snoring and sleep apnea are very similar in many ways, it’s important to note that not all snorers have sleep apnea, but all sleep apneics snore.

One study, which used in-laboratory polysomnography, found that the prevalence of sleep apnea in adults between 30 and 60 years of age was 9% for women and 24% for men. It is the risk of more severe disease that makes the medical diagnosis and management of sleep disorders so important for patients, as recognized by the ADA and the AMA. Any successful sleep therapy program must include a medical referral by a physician in order to manage this lifelong disease effectively.

Sleep apnea treatment can be accomplished in any general dental practice with materials that are customarily used in dentistry. The most common device used to treat sleep apnea, a mandibular advancement device (MAD), is essentially two mouthguards joined by a mechanism that allows a dentist to adjust the mandible forward in 1 mm increments until symptoms resolve.

Advancing the mandible puts lateral tension on the muscles and ligaments of the oral airway, supporting the tongue in a forward position — thereby clearing the airway. With a bilateral hinge device like the Silent Nite Sleep Appliance, there is a secondary benefit: The oblique traction mechanism of action holds the mouth closed, allowing patients to form a lip seal and breathe quietly through their nose.

In order to make a patient-specific MAD, Glidewell requires a dual-arch impression or scan and a protrusive bite registration. The Silent Nite appliance has an in-lab fabrication time of only three days. It is also available in a Glidewell Clinical Twinpak in case a patient loses or breaks the appliance; a backup appliance helps to ensure patients never go untreated. Clinicians may counsel their patients to wear the appliance whenever they sleep — even for an afternoon nap.

Dental providers of sleep apnea appliances often cite that medical reimbursement is perhaps the most difficult part of implementing sleep therapy into a dental office.

Several factors may be involved in the decision about accepting insurance plans, and the benefits of going in-network or out-of-network. However, the advantages of either option may depend on the location of the dental practice. Randy Curran, from Pristine Medical Billing, offers the following advice on this topic:

If there is an in-network dental sleep medicine provider within 20–30 miles of your practice, it would probably be best to become an in-network provider, as the insurance carrier is going to try to drive the patient to the other provider during the pre-authorization process. It will also be very difficult to obtain a gap approval to use the patient’s lower in-network deductible.

If there are no in-network competitors nearby, then the practice can stay out of the insurance network and obtain gap approvals to get the best of both worlds.

Note that a gap approval is when the insurance has a gap in coverage with a deficiency of in-network providers and allows the patient to see an out-of-network provider while using the better in-network benefits (lower deductible and cost share). The average in-network rate to treat sleep apnea with an oral appliance ranges between $1,700 and $2,500, depending on the carrier and region.

The decision to become a Medicare DME provider is also important. In some geographical locations, patients tend to be older, so Medicare provider status is a must. Curran provided the following advice regarding Medicare:

This depends on your patient demographics and if you are going to market yourself to the medical community down the road. Many providers enroll as a Medicare nonparticipating DME provider and charge the patient a fee up front, and the patient will be reimbursed directly from Medicare. The Medicare allowable ranges from $1,100 to $1,950 depending on the state. Some Medicare patients have a supplemental insurance that will at times pay the entire charge amount. These checks will go to the patients, so the practice must have a good collection protocol to ensure the patient pays all of the payments from both Medicare and the supplemental.

Insurance reimbursement is a recognized challenge and important issue in implementing dental sleep treatment in a dental office. The new CDT coding from the ADA is expected to help with reporting and standardizing terminology in the dental office. Currently, it remains to be seen how the codes will be greeted by medical and dental insurers. The availability of codes will not necessarily mean the procedure will be covered by insurance. However, this expansion could potentially open the opportunity for oral appliance therapy to move to dental insurance in the future.

Looking for a hands-on tool to enhance your communication with patients? Available for dental practices, the Sleep Appliance Sample Kit helps patients learn about various sleep devices during consultation. For more information or to order the kit, call 888-303-3975.