A night guard (occlusal splint or appliance) is a removable device worn over the teeth, typically during sleep, to protect them from damage caused by grinding or clenching. Coverage for this appliance is complicated because it exists at the intersection of dental and medical care. Coverage depends almost entirely on the underlying diagnosis and the specific purpose of the device. This purpose determines whether the claim is classified as a routine dental expense or a medically necessary treatment.
The Difference Between Dental and Medical Coverage
Most medical insurance plans contain a broad exclusion clause for routine dental care, which is the primary reason night guards are frequently denied. When a night guard is prescribed solely to prevent tooth wear from simple teeth grinding (bruxism), it is classified as a protective dental appliance. In this context, it is considered “dentally necessary” and is billed using Current Dental Terminology (CDT) codes, such as D9944 for a hard, full-arch guard.
Medical insurance plans define “medically necessary” as treatment for a diagnosed illness or injury, and simple bruxism often does not meet this standard. The goal of the night guard is to prevent future damage to the teeth, which falls under preventative or restorative dental work. While dental insurance policies may offer partial coverage, medical plans will almost always reject the claim when the diagnosis is limited to uncomplicated bruxism.
When Medical Insurance Might Cover a Night Guard
Medical coverage becomes a possibility only when the night guard treats a systemic medical condition that extends beyond the teeth. This reclassifies the appliance from a dental guard to a medical device. The two most common conditions that trigger medical coverage are severe Temporomandibular Joint Disorder (TMD) and Obstructive Sleep Apnea (OSA).
For a TMD diagnosis, which involves pain and dysfunction of the jaw joint and surrounding muscles, the appliance may be considered a therapeutic orthotic rather than a simple guard. The diagnosis must be documented by a physician using specific ICD-10 codes, such as M26.60 through M26.69, which relate to temporomandibular joint disorders. Similarly, an oral appliance designed to reposition the jaw and keep the airway open for mild to moderate OSA may be covered. For sleep apnea, the diagnosis must be confirmed by a sleep specialist following a formal sleep study, typically using ICD-10 code G47.33. This documentation proves the device treats a medical illness, not just dental surfaces.
Steps for Securing Medical Pre-Authorization
Successfully obtaining medical coverage, even with a qualifying diagnosis, almost always requires pre-authorization before the device is fabricated. The process begins with the diagnosing medical doctor (e.g., a sleep specialist or neurologist) providing a written prescription and a comprehensive letter of medical necessity. This letter must clearly explain why the oral appliance is the appropriate and least invasive treatment for the specific medical diagnosis, often referencing test results like sleep study data or MRI findings.
The next step involves the dental or oral appliance provider submitting the claim to the medical insurer, using medical billing codes instead of dental ones. For an OSA appliance, the provider must use a Healthcare Common Procedure Coding System (HCPCS) code, such as E0486, which identifies a custom-fabricated oral device for reducing upper airway collapsibility. This medical claim requires the physician’s diagnosis code (ICD-10) and detailed medical documentation to prove the severity of the condition. Thorough and accurate documentation, including clinical notes, X-rays, and the physician’s order, is paramount, as a missing or incorrect code will likely result in an immediate denial.
Options If Coverage Is Denied
If the medical insurance claim is denied, the first course of action is to initiate the internal appeal process with the insurer. Most plans offer a window of up to 180 days from the date of denial to file an appeal, requiring a formal letter and any new or missing clinical documentation. If the internal appeal is unsuccessful, the patient may request an external review by an independent third party, a process mandated in many states by healthcare regulations.
For those whose appeal is ultimately denied, alternative payment options exist to manage the cost. Night guards are considered an eligible medical expense, meaning funds from a Health Savings Account (HSA) or a Flexible Spending Account (FSA) can be used tax-free to cover the expense. Exploring options beyond the custom-made guard from a dental office may provide lower-cost alternatives. These include a custom-fitted guard from an online dental lab or, as a last resort, a boil-and-bite guard, though these are typically less effective.