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Phone: 408 910-8800

Is your treatment covered by insurance?

Many insurance companies will pay benefits for a sleep retainer under the provisions of the contract that covers Durable Medical Equipment. Treating your sleep apnea with an oral appliance, or what I like to call “sleep retainers” are not covered by your dental insurance plan. Kaiser and HMOs will not pay me to treat you with a sleep retainer. But, if your HMO has a EPO option, then you might receive benefits for treating your snoring and/or sleep apnea.

Dr. Hilton is not in any networks and neither are 99.5% of dentists that treat sleep apnea with an oral appliance. There are several reasons for this? From a medical insurance standpoint, this is a very new treatment for patients. The carriers have not seen enough of these to warrant letting ‘general dentists’ in network for the services. The vast majority of the claims are for CPAP machines!

A second reason is a sleep retainer is listed as durable medical equipment by every insurance plan. This means that Dr. Hilton is being recognized as a “provider of a piece of medical equipment” and not as a dentist or a “quasi-physician” so inclusion in a network may never be necessary.

But we routinely obtain benefits for patients as though Dr. Hilton is an “in-network provider.” We can obtain GAP coverage, which means that you get insurance benefits as though Dr. Hilton was in-network with the company. If you want, we can send you a copy of a letter showing this process being successfully completed for one of our patients.

Before paying benefits, all of them will require evidence of medical necessity. This includes a referral from your personal MD or the sleep med physician treating you and a current sleep study. The definition of what is a “current study” varies with each plan. If your sleep study is more than 6 years old, you will probably need a new one.

Before making an appointment, you can call your insurance company to see if you have benefits for durable medical equipment. You will need to give them this medical code: E0486. If you would like us to do this for you, just call our office and we can get the information for you.