What Dental Insurance Covers Night Guards?

A night guard is a custom-fit oral appliance designed to protect teeth and alleviate symptoms associated with bruxism (teeth grinding or clenching) and temporomandibular joint (TMJ) disorders. These devices serve as a barrier between upper and lower teeth, preventing wear and tear and reducing jaw strain. Understanding dental insurance coverage for night guards is a common concern. Coverage varies significantly by plan and the reason for the night guard, requiring a thorough understanding of policies.

General Dental Insurance Coverage for Night Guards

Dental insurance coverage for night guards depends on an individual’s plan and medical justification. Most dental plans cover custom-fit night guards if a dentist determines they are medically necessary. Over-the-counter (OTC) night guards are typically not covered. Custom-made night guards are considered for coverage because they are prescribed by a dentist and fabricated from a patient’s mold.

Insurance companies often classify custom night guards under “major restorative” or “prosthodontic” services. Some plans might cover a percentage of the cost. Insurers may also impose frequency limitations, such as covering a replacement night guard only every three to five years.

Key Factors Determining Coverage

A diagnosis from a licensed dentist is required for a night guard to be considered for insurance coverage. It must be medically necessary, requiring documentation of conditions like bruxism, severe clenching, or TMJ disorder. Diagnostic evidence, such as X-rays or other imaging, is frequently requested.

Specific diagnostic (ICD-10) and procedure (CDT) codes are critical for claim submission. For instance, G47.63 is an ICD-10 code for sleep-related bruxism, while M26.6 is used for temporomandibular joint disorders. Common CDT codes are used for night guards. These codes help insurers understand the condition and appliance provided.

Pre-authorization is often required for custom night guards. This involves submitting documentation, including dentist’s notes, X-rays, and the proposed treatment plan, for approval. Obtaining pre-authorization helps determine potential coverage and minimizes unexpected out-of-pocket expenses.

Policy limitations also influence coverage. These include annual maximums ($1,000-$2,000) and deductibles ($50-$150 per person) that must be met before insurance pays. Co-insurance percentages dictate the patient’s portion of the cost after the deductible (20%-50% for major services). Waiting periods (six to twelve months) may also apply. If TMJ is involved, some plans might cover the night guard under medical insurance rather than dental, requiring different medical CPT and ICD-10 codes.

Checking Your Specific Dental Plan

Understanding your individual dental plan’s specifics is essential. Access your policy documents, available through online portals or a summary of benefits. These documents contain your coverage terms and conditions.

When reviewing your policy, look for terms such as “oral appliances,” “occlusal guards,” “bruxism treatment,” “TMJ treatment,” or “splints.” Even if a night guard is not explicitly listed, its coverage might fall under broader categories like major restorative or prosthodontic services.

Contacting your dental insurance provider directly is a way to confirm coverage. Reach their member services department via phone, online chat, or secure messaging. Have your policy number ready and ask specific questions for precise information.

Inquire whether a custom night guard is covered and what percentage of the cost is covered. Ask if pre-authorization is required for the specific CDT code your dentist plans to use, along with the corresponding ICD-10 diagnosis code. Confirm your remaining deductible, co-insurance percentage, and any annual maximums or frequency limitations. After a claim is processed, you will receive an Explanation of Benefits (EOB), detailing what the insurer paid, your deductible, and your remaining financial responsibility.

Managing Costs and Uncovered Expenses

Even with dental insurance, patients may incur out-of-pocket expenses for a night guard due to deductibles, co-insurance, or charges exceeding “usual and customary” rates. After insurance coverage is applied, you are responsible for any remaining balance. Understanding these costs upfront helps in financial planning.

Options exist for managing uncovered expenses. Many dental offices offer payment arrangements, allowing patients to pay over time. Third-party financing options, such as CareCredit, provide specialized healthcare credit lines to cover immediate costs.

Additionally, Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) can be used for eligible dental expenses, including night guards. These accounts allow you to set aside pre-tax dollars, reducing overall healthcare costs. HSAs typically roll over year to year, while FSAs often have a “use it or lose it” rule by year-end.

If a claim for a night guard is denied, policyholders have the right to appeal. The appeals process generally involves submitting additional documentation, such as clinical notes, radiographs, and a letter of medical necessity from your dentist, to support the claim. Understanding the reason for the denial, as stated on the Explanation of Benefits, is the first step in preparing an effective appeal.