Myofunctional therapy (MFT) is an exercise-based program that targets the muscles of the face, mouth, and tongue to correct abnormal movement patterns known as orofacial myofunctional disorders (OMDs). These exercises aim to improve functions like proper tongue rest posture, lip seal, swallowing, and nasal breathing. MFT is often recommended for conditions such as tongue thrust, malocclusion, and sleep-disordered breathing, including obstructive sleep apnea. Determining insurance coverage for MFT is highly variable and complex due to its classification in the healthcare system.
Classification: Medical vs. Dental Coverage
The primary challenge in securing insurance coverage for myofunctional therapy is that it often exists in a gray area between medical and dental benefits. Dental insurance rarely covers MFT, as it is generally designed for preventative care, routine procedures, and major restorative work.
Medical insurance may offer coverage if the treatment is deemed medically necessary to resolve a diagnosed health condition. The specific diagnosis dictates the billing category, such as billing under a medical plan for sleep apnea or swallowing difficulties. If the therapy is primarily to support orthodontic work or cosmetic improvements, it is far less likely to be covered.
Documentation and Criteria for Approval
For an insurance company to consider covering myofunctional therapy, the treatment must be backed by documentation establishing medical necessity. This requires a formal diagnosis of an orofacial myofunctional disorder or a related medical condition, such as sleep-disordered breathing, dysphagia, or certain speech impairments. The payer looks for objective evidence that the therapy is a non-elective treatment for a functional impairment.
The therapist submits claims using standardized Current Procedural Terminology (CPT) codes, which are five-digit codes used to describe the services performed. Common codes used for MFT include those for therapeutic exercises or neuromuscular re-education (e.g., 97110 or 97112), or codes related to speech and swallowing treatment (e.g., 92507 or 92526). These procedure codes must be paired with an International Classification of Diseases (ICD) code, which corresponds to the specific medical diagnosis, such as G47.33 for obstructive sleep apnea.
Many insurance plans require pre-authorization before treatment begins to confirm coverage and reduce the risk of a denied claim. This involves the provider submitting the treatment plan, diagnosis codes, and supporting clinical notes for review. A referral from a specialist, such as a physician or sleep specialist, can strengthen the case for medical necessity by establishing a link between the OMD and a systemic health issue.
Practical Steps for Verifying Coverage
The most effective way to determine coverage is for the patient or provider to contact the insurance carrier directly for a verification of benefits. When speaking with the insurance representative, it is important to be specific and ask about coverage for the proposed CPT codes, not just “myofunctional therapy” in general. The representative can confirm if the services are covered, what percentage is reimbursed, and if the provider is considered in-network or out-of-network.
Patients should also inquire about their deductible status, as MFT costs will likely be applied to the yearly deductible before benefits begin. If the therapist is out-of-network, the patient should understand the specific out-of-network benefits, which are typically lower than in-network rates. Obtaining a written confirmation or a reference number for the call is recommended, as verbal confirmations are not binding for the insurance company.
If the claim is initially denied, patients have the right to appeal the decision by submitting additional documentation, a detailed letter from the treating therapist, and a letter of medical necessity from a supervising physician. The therapist can provide a “superbill,” which is a detailed invoice with all the necessary procedure and diagnosis codes, allowing the patient to submit a claim for out-of-network reimbursement. This process is largely the patient’s responsibility, as many myofunctional therapists operate as fee-for-service practices.
Alternative Payment and Financial Options
When insurance coverage is denied or unavailable, alternative financial options can make myofunctional therapy more accessible. Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) can be used to pay for MFT, as these funds are designated for qualified medical expenses. Using HSA or FSA funds allows patients to pay for treatment with pre-tax dollars, which reduces the overall cost.
In cases where out-of-network reimbursement is sought, the patient may submit a claim with a superbill and often receive partial payment if they have out-of-network benefits. Many practices also offer in-house payment plans to help manage the cost of treatment, which often falls between $1,800 and $2,500 for a full program. Patients paying out-of-pocket should consult a tax professional about potential medical expense deductions if their total medical costs exceed a certain percentage of their adjusted gross income.