The Short Answer
A custom sleep apnea oral appliance often costs somewhere in the low thousands of dollars before insurance. The American Sleep Apnea Association says custom devices "can cost thousands of dollars," and that medical or dental insurance may cover some of the cost. [4] Prices vary by office, city, device type, and how much follow-up is included, so treat any number you read online, including ones on this page, as a starting point for questions rather than a quote.
The most important insurance fact is this: an oral appliance for diagnosed sleep apnea is generally a medical treatment, not a dental one. That means it is usually billed to your medical insurance, and dental insurance often will not pay for it. Original Medicare can cover it, but only if specific rules are met. This guide explains those rules and gives you questions to ask before you pay anything.
A note on scope: this page is general information, not a coverage promise. Your plan documents and the office's billing staff have the final word on what you will owe.
What Does an Oral Appliance Cost?
Published pricing guides from sleep and dental practices give wide ranges. One ENT clinic's guide says mandibular advancement devices generally range from $500 to $4,500, with custom devices at the higher end because of professional fees, impressions, and lab work. [5] Over-the-counter boil-and-bite products usually cost far less, but they are not custom and are not what the guideline recommends for treating diagnosed sleep apnea. [3] [4]
Why the wide range? Cost depends on:
- The type of device and the lab that makes it
- Whether the price includes the exam, scans or impressions, adjustments, and follow-up visits, or bills them separately
- Your location and the office's fee schedule
- Whether the office bills your medical insurance, and what your plan allows
- Whether you need dental work first, such as treating gum disease or fixing a broken tooth
What Is Included in the Price
Ask for an itemized estimate. A complete oral appliance program usually has these parts:
Exam and records
The dentist reviews your sleep test and physician prescription, examines your teeth, gums, and jaw joints, and takes impressions or digital scans. The AASM and American Academy of Dental Sleep Medicine guideline says a qualified dentist should use a custom, adjustable appliance for adults with OSA. [3]
The device itself
Custom devices are made from your scans in a dental lab. The guideline suggests custom, titratable (adjustable) devices over non-custom ones. [3]
Adjustment (titration)
Titration means gradually moving the lower jaw forward over several visits to find the setting that works well and is still comfortable. The American Sleep Apnea Association says the dentist makes periodic adjustments over several months. [4]
Follow-up and testing
The guideline suggests periodic dental visits to watch for dental side effects and bite changes, and follow-up sleep testing ordered by a physician to confirm the device works. [3] The sleep test is usually billed separately by the physician's office, so ask who pays for it.
Why It Is Usually Billed to Medical Insurance
Sleep apnea is a medical diagnosis. It is made by a physician after a sleep test, and the oral appliance is a treatment prescribed for it. The National Heart, Lung, and Blood Institute lists custom-fitted oral appliances among the medical treatments for sleep apnea. [6] Insurers therefore generally handle it under the medical plan. Dental plans are built for teeth and gums, and many exclude sleep apnea devices. Some dental plans may still contribute, so ask, but do not assume.
Medicare follows this logic. Its policy article says oral appliances used to treat OSA are covered under the durable medical equipment (DME) benefit. [2] It also says that some appliances are classified as dental devices and are denied as not DME, including tongue-retaining devices, appliances used only for snoring without an OSA diagnosis, and appliances for TMJ disorders. [2]
For the treatment itself, see our guide to dental treatment for sleep apnea.
Medicare Coverage: What the Rules Say
Original Medicare covers a custom oral appliance for OSA when all of the coverage criteria in the Local Coverage Determination (LCD) for oral appliances, L33611, are met. This policy has been in effect since October 2015, and the revision we reviewed took effect on August 8, 2021. [1] The related policy article is A52512. [2] Rules can change, so confirm the current version with the office or on the Medicare Coverage Database.
The billing code: E0486
Medicare uses HCPCS code E0486 for a custom fabricated mandibular advancement device. The policy article defines a custom device as one made for a single person from a full-arch impression, taken with materials or digital images, that is used to create a model. To be coded E0486, the device must also have features such as a fixed mechanical hinge and the ability to move the jaw forward beyond the front teeth. Devices that do not meet the definition are coded as non-covered. [2]
Prefabricated appliances, coded E0485, are denied. The LCD says there is not enough evidence that they are effective therapy for OSA. [1]
The coverage criteria
The LCD says a custom appliance is covered if four conditions (A through D) are met. [1]
- A. You had an in-person clinical evaluation by a treating practitioner before the sleep test. The LCD defines this as a physician, nurse practitioner, clinical nurse specialist, or physician assistant. It does not include a dentist. [1]
- B. You have a Medicare-covered sleep test that meets one of three sets of results. Route 1: an AHI or respiratory disturbance index (RDI) of 15 or more events per hour, with at least 30 events. Route 2: an AHI or RDI of 5 to 14 events per hour, with at least 10 events, plus documented sleepiness, impaired cognition, mood disorder, or insomnia, or documented high blood pressure, ischemic heart disease, or stroke. Route 3: an AHI or RDI over 30 and either an inability to tolerate a positive airway pressure device or a practitioner's determination that PAP is contraindicated. [1]
- C. The device is ordered by the treating practitioner after reviewing the sleep test report. [1]
- D. The device is provided and billed for by a licensed dentist (DDS or DMD). [1]
Does severe OSA require a failed CPAP trial?
This is the question people ask most. The written criteria do not clearly say so. Route 3 ties an AHI over 30 to PAP intolerance or a contraindication. But Route 1 already covers an AHI of 15 or more, which includes severe OSA. Read together, the text does not obviously make a failed CPAP trial mandatory for every claim. Still, offices and reviewers can interpret coverage differently, and many practices document CPAP intolerance to be safe. Ask the office how they handle it. [1]
Other Medicare rules to know
Follow-up care, including fitting and adjustments, during the first 90 days after you receive the appliance is included in the payment for the device. Adjustments and follow-up visits after 90 days are not covered under the DME benefit, and appliances that need repeated fitting after the first 90 days to stay effective are treated as dental devices. [2]
Medicare lists a 5-year reasonable useful lifetime. A device can be replaced at the end of five years, or earlier in cases of loss, theft, or irreparable damage from a specific accident or natural disaster. Wear and tear from ordinary use is not covered for early replacement. [2] Repairs are covered for items that meet coverage criteria. [2]
The policy article also requires a written order before delivery and a face-to-face encounter for certain DME items. If the supplier delivers the device before getting the order, payment is denied even if the order comes later. [2] The LCD also says DMEPOS suppliers must keep proof of delivery. [1]
The office must be set up to bill Medicare
Because Medicare covers these devices as durable medical equipment, the dentist has to provide and bill for the device under Medicare's DME rules. [1] [2] In practice, that generally means the dental practice is enrolled with Medicare as a DMEPOS supplier. Many general dental offices are not, so ask directly before you book. If the office is not enrolled, Medicare may not pay for a device from that office, even if you meet every clinical criterion. Medicare Advantage plans may have their own networks and authorization steps, so call the plan too.
Prior Authorization and Paperwork
Many private insurers require prior authorization for oral appliances, which means they must approve the device before the office makes it. Requirements vary by plan, and there is no single national rule for private plans, so ask your insurer directly. Documents an insurer may ask for include your sleep test report, the physician's diagnosis and prescription, and notes on any CPAP problems.
Ask the dental office to check your benefits and submit the request before your scans, not after. A denial before you pay is easier to deal with than a denial after.
FSA and HSA Accounts
Health savings accounts (HSAs) and flexible spending accounts (FSAs) often pay for medical care that is not covered by insurance. A physician-prescribed device to treat a diagnosed medical condition is a strong candidate. Eligibility rules differ by plan, so check with your plan administrator and ask the dental office for an itemized receipt and a prescription or letter of medical necessity. Over-the-counter snoring devices are less likely to qualify.
Questions to Ask the Office Before You Pay
Bring this list to your consultation or call the office in advance.
- Do you bill medical insurance for oral appliances? Are you enrolled as a Medicare DMEPOS supplier?
- Will you check my benefits and get prior authorization before you make the device?
- What is the total out-of-pocket estimate, in writing? What does it include?
- How many follow-up and adjustment visits are included, and for how long? What happens after 90 days?
- Who orders and pays for the follow-up sleep test?
- What brand and type of device will you use, and is it custom and adjustable?
- What happens if the device does not work or I cannot tolerate it? Is there a refund policy?
- What is the replacement cost if it breaks or after several years?
- Will you coordinate with my sleep physician and send them reports?
Get a Diagnosis, Then Find a Dentist
Insurance requires a diagnosis, and so does good care. A physician has to diagnose sleep apnea with a sleep test, in a lab or at home, before an oral appliance is prescribed. [3] The dentist then makes and adjusts the device. Dental sleep medicine is not a recognized dental specialty, so look for a dentist with training in it. Our guide to CPAP alternatives and comparison of oral appliances and CPAP can help you prepare.
Once you have your diagnosis, search our provider directory for dentists near you. A prosthodontist may offer oral appliance therapy, as do some general dentists. Use the questions above to compare offices, then confirm coverage with your insurer before you start. Browse our list of dentists who provide oral appliance therapy, grouped by state.
