Are Mouth Guards Covered by Insurance?

Mouthguards are oral devices worn over the teeth, serving various purposes from protecting against physical impact to treating specific oral health conditions. While these appliances offer important benefits, determining insurance coverage can be complex. Coverage is not universal and often depends on the mouthguard type, your insurance policy, and the medical or dental reason for its use. Understanding these distinctions helps navigate the financial aspects of obtaining a mouthguard.

Types of Mouthguards and Insurance Categories

Mouthguards are categorized by function, influencing how insurers classify them for coverage. Athletic mouthguards, designed for sports, typically fall under preventive or optional care. They are usually not covered by medical or dental insurance, as they are considered discretionary for injury prevention. Some dental plans may offer partial coverage for custom-made athletic mouthguards if deemed a necessary preventative measure.

Night guards, used to prevent tooth damage from bruxism or teeth grinding, are often considered for coverage under dental insurance. Coverage typically requires a diagnosis of bruxism or a related condition, along with documentation from a dentist indicating medical necessity. Common Current Dental Terminology (CDT) codes include D9944, D9945, and D9946. If covered, dental plans might reimburse between 50% to 80% of the cost.

Temporomandibular Joint (TMJ) splints or orthotic devices treat jaw joint disorders. These are often considered medical devices because TMJ disorders are classified as joint and muscle conditions, not purely dental issues. Coverage for TMJ splints is commonly sought under medical insurance, especially when prescribed by a physician or dentist for a diagnosed TMJ disorder. However, coverage can be inconsistent, as some medical insurers may consider it too dental-focused, while some dental insurers may view it as too medical, leading to gaps.

Oral appliances designed to treat obstructive sleep apnea (OSA) are typically covered by medical insurance. These custom-fabricated mandibular advancement devices are classified as durable medical equipment (DME). Coverage requires a formal OSA diagnosis, usually confirmed through a sleep study. A physician’s prescription or letter of medical necessity is also required. The Healthcare Common Procedure Coding System (HCPCS) code E0486 is used for billing.

Verifying Your Coverage

Verify your insurance coverage before purchasing a mouthguard. Review your policy documents for both medical and dental plans. Look for sections detailing coverage for “prosthetics,” “oral appliances,” “dental care,” “medical devices,” or “preventive care.” Note terms such as deductibles, co-insurance, co-pays, annual maximums, and whether your provider is in-network or out-of-network, as this affects your out-of-pocket expenses.

Contact your insurance provider directly, using the number on your insurance card or their online portal. Ask specific questions about coverage for your mouthguard type and condition (e.g., bruxism, TMJ disorder, or obstructive sleep apnea). Inquire about the CPT or CDT codes required for coverage and the expected reimbursement percentage.

Confirm if pre-authorization or a referral is necessary and understand the process. Ask about provider requirements, such as using an in-network dentist. Inquire what documentation, like a diagnosis code, prescription, or letter of medical necessity, is needed for your claim. Document all communications, including date, time, representative’s name, and reference numbers. Obtaining written confirmation of coverage or pre-authorization helps prevent future misunderstandings or claim denials.

The Reimbursement Process

After obtaining your mouthguard and confirming coverage, submit a claim for reimbursement. Gather all required documentation, including a detailed receipt from the provider showing the total cost and relevant CPT or CDT codes.

If required, include a prescription or letter of medical necessity from the prescribing professional, explaining why the mouthguard is medically necessary. Also include any pre-authorization numbers obtained prior to receiving the mouthguard.

Submit the claim through your insurance provider’s online portal or by mailing a completed claim form. Accurately enter all patient and provider details, service codes, and the total cost.

After submitting your claim, you will receive an Explanation of Benefits (EOB) from your insurance company. This document details how your claim was processed, including the approved amount, any portion applied to your deductible, and your remaining patient responsibility. Review the EOB carefully for accuracy. If there are delays or issues, follow up by checking the claim status online or contacting member services. If a claim is denied, you have the right to appeal, often requiring additional medical records or a supporting letter from your healthcare provider.