Is a Mouth Guard Covered by Insurance?

Mouthguards are oral appliances that protect teeth and address various oral health concerns. They are used for safeguarding teeth during sports, managing teeth grinding (bruxism), and treating temporomandibular joint (TMJ) disorders. Insurance coverage for mouthguards depends on factors specific to an individual’s plan and the device’s medical necessity.

General Coverage Principles for Mouthguards

Insurance coverage for mouthguards depends on whether the device is medically necessary and which type of insurance applies. Dental insurance plans often cover 50% to 80% of the cost. Medical insurance may also provide coverage if the mouthguard treats a diagnosed medical condition.

Coverage relies on the mouthguard’s medical necessity, linking it to a diagnosed condition rather than general prevention or athletic use. Night guards for bruxism, TMJ splints, or oral appliances for sleep apnea are more likely to be covered when prescribed by a healthcare professional. Athletic mouthguards are generally not covered by insurance as they are not considered medically necessary for a diagnosed condition. For bruxism or TMJ, a letter of medical necessity from a dentist or doctor, along with diagnostic evidence like X-rays, strengthens a claim. Oral appliances for sleep apnea may also be covered by medical insurance, often requiring pre-authorization and a sleep study report.

Financial Considerations and Policy Specifics

Understanding the financial terms of an insurance policy helps determine out-of-pocket costs for a mouthguard. A deductible is the amount an individual must pay for covered services before the insurance plan contributes. This amount typically resets annually.

After the deductible is met, co-insurance is the percentage of the cost an individual is responsible for, with the insurance paying the remainder. For example, an 80/20 co-insurance means the plan pays 80% and the individual pays 20% of the covered service. Co-pays are fixed amounts paid for a service at the time of visit.

An out-of-pocket maximum represents the most an individual will pay for covered services within a policy year, after which insurance typically covers 100% of additional costs. Pre-authorization, or prior approval, is often necessary for medically necessary or more expensive mouthguards, confirming coverage before treatment. Some dental benefits may also have waiting periods before full coverage for certain procedures becomes active.

Confirming Your Coverage Details

To determine specific coverage for a mouthguard, review the Summary of Benefits and Coverage (SBC) document for your plan. This document outlines what is and is not covered, including details on deductibles, co-insurance, and co-payments. The SBC also provides information on where to find complete plan documents and contact information.

Contacting the insurance provider directly is a primary method for gathering precise coverage information. The phone number is typically found on the insurance ID card or through the insurer’s online portal.

When calling, ask specific questions, such as whether a particular CPT (Current Procedural Terminology) or CDT (Current Dental Terminology) code is covered for a specific diagnosis code (ICD-10). Inquire about pre-authorization requirements and the applicable deductible, co-insurance, and co-pay for the service.

Documenting call details, including the date, time, and representative’s name, or requesting information in writing, can be beneficial for future reference. Many dental offices have experience with insurance claims and can assist in understanding coverage specifics.

The Process for Obtaining Coverage

Once coverage details are confirmed, the dentist’s office typically manages billing and claim submission to the insurance company. This process involves using accurate diagnosis codes (ICD-10) that specify the medical condition being treated and procedure codes (CPT/CDT) that identify the type of mouthguard provided.

The dental office may need to provide supporting documentation, such as a letter of medical necessity, X-rays, or impressions, to substantiate the claim. After the claim is submitted, the individual receives an Explanation of Benefits (EOB) from their insurer. The EOB details the services billed, the amount insurance covered, and the remaining patient responsibility.

If a claim is denied, the EOB will provide a reason. An appeals process is typically available, which involves submitting a written request for reconsideration with additional documentation or clarification within a specified timeframe.