Are Night Guards Covered by Insurance?
Understand night guard insurance coverage. Learn key factors, verify your benefits, and navigate the process of obtaining your device.
A night guard is a dental appliance worn during sleep to protect teeth from grinding or clenching (bruxism) and alleviate symptoms of temporomandibular joint (TMJ) disorders, such as jaw pain and headaches. Understanding insurance coverage is important, as the cost can be a consideration.
Understanding Different Types of Night Guards
Different types of night guards are available, and their design and origin influence potential insurance coverage. Over-the-counter (OTC) night guards, found in drugstores, typically include “boil-and-bite” or one-size-fits-all options. These are more affordable and accessible, allowing users to mold them at home. However, due to their non-customized nature and lack of professional supervision, OTC night guards are typically not covered by insurance.
Custom-fitted night guards are prescribed by a dentist and tailored precisely to an individual’s dental impressions. This professional approach ensures a more accurate fit, greater durability, and enhanced effectiveness. These guards are crafted in a dental lab from impressions taken during a dental visit, often using materials like hard acrylic or softer plastics. Custom-fitted night guards may be eligible for insurance coverage, given their medical purpose and professional fabrication.
Key Factors Influencing Insurance Coverage
Insurance coverage for a custom-fitted night guard depends on whether the claim falls under medical or dental insurance. Dental insurance typically covers night guards for issues directly affecting the teeth, such as bruxism, often classifying them under preventive or restorative care. Common dental codes for occlusal guards include D9944 (hard appliance, full arch), D9945 (soft appliance, full arch), and D9946 (hard appliance, partial arch).
Medical insurance may provide coverage if the night guard is part of a broader treatment plan for conditions like TMJ disorders or chronic headaches. In such cases, the night guard must be deemed medically necessary by a qualified healthcare professional, requiring a formal diagnosis. Insurance policies often have limitations like deductibles (amounts paid out-of-pocket before coverage begins), co-pays, or co-insurance (portions of the cost the patient remains responsible for). Annual maximums, which limit the total amount an insurer will pay in a year, and waiting periods can also impact coverage. Choosing an in-network provider often leads to higher coverage percentages, typically ranging from 50% to 80% of the allowable amount.
How to Verify Your Specific Coverage
Begin by reviewing your insurance policy documents, including the benefits summary or policy handbook, which may be available through your insurer’s online member portal. These documents often outline coverage for dental appliances or medical devices.
The most direct way to confirm coverage is to contact your insurance provider directly using the member service number on your insurance card. When speaking with a representative, have your policy number ready and be prepared to discuss any diagnosis codes provided by your dentist or doctor. Ask specific questions:
Is a custom-fitted night guard covered for your diagnosed condition?
What specific CDT or CPT codes are covered?
What are the amounts for deductibles, co-pays, and co-insurance?
Are there any annual limits, replacement clauses, or pre-authorization requirements?
Document all communications, including the date, time, representative’s name, and the information provided.
Steps for Obtaining a Night Guard
Once insurance coverage is confirmed, obtaining a custom-fitted night guard begins with a consultation with your dentist or doctor. This initial visit allows the professional to diagnose the underlying condition, such as bruxism or TMJ disorder, and discuss treatment options. Clearly communicate the need for a custom guard and the associated diagnosis for proper insurance documentation.
Following the diagnosis, the professional will provide a prescription or recommendation for the night guard. Impressions of your teeth are then taken, either through traditional molds or digital scans, to ensure the night guard is precisely custom-made. After fabrication in a dental lab, you will return for a fitting appointment where the dentist makes any necessary adjustments.
Your provider’s office typically submits the claim to your insurance, and you will receive an Explanation of Benefits (EOB) statement detailing costs covered by insurance and your remaining financial responsibility. Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs) can often be used for any out-of-pocket costs, as night guards are generally considered eligible medical expenses. Regular follow-up visits are important for adjustments and maintenance.