Are Mouthguards Covered by Insurance?

Mouthguards are custom-fitted devices designed to protect teeth and oral structures. They serve multiple purposes, including safeguarding against sports injuries, mitigating teeth grinding (bruxism), and assisting with sleep-related breathing disorders. Obtaining a mouthguard often raises questions about insurance coverage, which can be complex due to different types of mouthguards and varying insurance policies. Understanding coverage requires considering the mouthguard’s intended use and your plan’s specific terms.

Types of Mouthguards and Insurance Relevance

Mouthguards fall into two categories: over-the-counter (OTC) options and custom-made devices. OTC mouthguards, like stock or “boil-and-bite” varieties, are widely available and typically cost between $20 and $50. These options offer basic protection but are usually not covered by dental or medical insurance due to their generic fit and lack of medical necessity documentation.

Custom-made mouthguards, fabricated by a dental professional, offer a precise fit and superior protection or therapeutic benefits. They are categorized by function: athletic mouthguards, nightguards for bruxism or temporomandibular joint (TMJ) disorders, and oral appliances for sleep apnea. Custom athletic mouthguards, often costing $100 to $700, prevent dental injuries during sports. Nightguards, ranging from $300 to $800, alleviate teeth grinding and clenching symptoms by providing a protective barrier. Oral appliances for sleep apnea, usually more expensive, reposition the jaw and tongue to keep the airway open, and their prescribed purpose influences eligibility for dental, medical, or both types of insurance coverage.

Custom-made mouthguards for medical or dental conditions, such as bruxism or sleep apnea, are more likely to be considered for insurance coverage due to their therapeutic nature. For instance, a nightguard for bruxism addresses a diagnosed medical condition, potentially making it eligible for dental insurance. An oral appliance for sleep apnea, a medical condition, is often covered under medical insurance as durable medical equipment (DME). In contrast, athletic mouthguards, while preventative, are typically considered elective and rarely covered by insurance.

Understanding Insurance Coverage for Mouthguards

Determining mouthguard coverage requires understanding your insurance policy. First, distinguish between dental and medical insurance plans, as each covers different services. Nightguards for bruxism or TMJ disorders might be covered by dental insurance, especially if they fall under preventative or restorative benefits. If the bruxism or TMJ disorder is deemed medically necessary and linked to broader health issues, medical insurance might offer coverage, often classifying the oral appliance as durable medical equipment.

To confirm coverage, review the Summary of Benefits and Coverage (SBC) from your insurer. This document outlines covered services, limitations, and costs. Look for terms like “oral appliances,” “dental prosthetics,” “TMJ treatment,” or “sleep apnea devices.” Dental procedures use Current Dental Terminology (CDT) codes, such as D9944 for a hard occlusal guard for a full arch, and D9941 for athletic mouthguards. Medical insurance, on the other hand, uses Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes, along with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes, such as G47.63 for sleep-related bruxism or M26.6 for TMJ disorders.

Contacting your insurer directly is often the most effective way to confirm coverage. Inquire about specific CPT or CDT codes relevant to the mouthguard needed. Ask if pre-authorization is required for custom oral appliances, as many plans mandate this step before treatment begins. Clarify deductible amounts, co-insurance percentages, and out-of-pocket maximums that apply, as many insurers require a prescription from a licensed medical or dental professional, along with supporting diagnostic (ICD-10) codes that establish medical necessity. For instance, a sleep study documentation is typically required for sleep apnea appliances.

Navigating the Coverage Process and Costs

Once you understand your insurance policy, navigating the coverage process involves several practical steps. If pre-authorization is required, the dental or medical office will typically submit documentation to the insurer for approval before fabricating the mouthguard. This process can take several days to a few weeks, with some insurers responding within 5-10 business days. Confirm that your treating dentist or medical provider is within the insurance network to maximize benefits and minimize out-of-pocket expenses. In-network providers have negotiated rates, usually resulting in lower patient costs.

Claim submission is usually handled by the provider’s office, which submits diagnosis codes (e.g., for bruxism or TMJ) and procedure codes (e.g., for a nightguard or sleep apnea devices) to the insurance company. Patients should retain copies of all submitted forms, including the prescription and any diagnostic results. Understanding the bill involves recognizing how deductibles, co-insurance, and out-of-pocket maximums apply. For example, if a custom nightguard costs $500 and the plan has a 50% co-insurance after a met deductible, the patient would be responsible for $250.

In the event of a claim denial, avenues for appeal exist. First, review the denial letter to understand the specific reason for refusal. Common reasons include insufficient documentation, lack of medical necessity, or the service not being covered, but patients have the right to an internal appeal with their insurance company, requesting a full review and submitting additional supporting documentation, such as a letter of medical necessity from the provider. If the internal appeal is unsuccessful, an external review by an independent third party may be pursued. This process typically has deadlines, often around 180 days from the denial notice for internal appeals.