Myofunctional therapy (MFT) is a specialized program of exercises designed to retrain the muscles of the face, mouth, and throat, which are responsible for chewing, swallowing, speaking, and breathing. This therapy corrects improper resting postures of the tongue and lips and dysfunctional muscle patterns. Coverage for MFT is highly nuanced and complex, depending heavily on the specific medical diagnosis and the type of insurance plan. Reimbursement is not guaranteed and relies on whether the insurer deems the treatment “medically necessary.”
Conditions That May Qualify for Coverage
Insurance companies are most likely to cover MFT when it is prescribed to treat a documented medical condition, rather than for cosmetic or orthodontic reasons. The determination of “medical necessity” is required for potential reimbursement. Common diagnoses that meet this requirement relate to airway function and orofacial pain.
MFT is often prescribed for individuals with sleep-disordered breathing, including mild to moderate obstructive sleep apnea (OSA), where improper muscle function contributes to airway collapse. By strengthening and coordinating the tongue and throat muscles, MFT can improve airway patency and reduce the severity of breathing disruptions during sleep. This functional improvement is key to establishing medical necessity.
Orofacial and Swallowing Disorders
Treatment for temporomandibular joint disorders (TMD), which involve pain and dysfunction in the jaw joints and muscles, is another potential area for coverage. Muscle retraining helps stabilize the jaw and alleviate chronic pain associated with these disorders. Conditions like chronic tongue thrust or difficulty swallowing (dysphagia) also frequently warrant MFT. Dysphagia is a clear medical diagnosis, and MFT, often billed as therapeutic exercises or neuromuscular re-education, is a recognized treatment for improving the strength and coordination required for safe swallowing. In these cases, the therapy is viewed as a functional intervention aimed at correcting a physiological impairment. A documented diagnosis from a physician, such as an ICD-10 code for sleep apnea (G47.33) or a swallowing disorder (R13.10), is the necessary starting point for any insurance claim.
Classification Challenges for Insurance Coverage
The primary reason coverage for myofunctional therapy is so inconsistent stems from its ambiguous classification within the healthcare system, frequently falling into a gray area between medical and dental care. Insurers often lack a specific, dedicated policy for “myofunctional therapy” as a standalone treatment category. This often leads them to categorize the treatment as “experimental” or “investigational,” even when used to treat a recognized medical problem.
The billing process itself presents a major hurdle, requiring providers to use Current Procedural Terminology (CPT) codes typically associated with speech pathology or physical therapy. Examples include CPT codes like 97110 for therapeutic exercises or 97112 for neuromuscular re-education. The provider must select a CPT code that accurately reflects the service performed and pair it with a specific International Classification of Diseases, Tenth Revision (ICD-10) code to establish medical necessity, such as a diagnosis for sleep apnea or dysphagia.
Billing and Network Issues
If the CPT code used is not generally accepted for the specific diagnosis, or if the insurer has an internal policy classifying the treatment as unproven, the claim will be denied. Many MFT providers are not in-network with insurance companies, which forces patients to seek less favorable out-of-network reimbursement. Furthermore, if the treatment is primarily aimed at correcting malocclusion or preventing orthodontic relapse, the claim may be directed to dental insurance, which usually offers limited benefits. This structural mismatch creates a systemic barrier to consistent coverage.
Practical Steps to Verify Your Plan Coverage
The burden of verifying coverage falls almost entirely on the patient. The first step involves securing a formal prescription or referral from a medical doctor, such as a sleep specialist or an ear, nose, and throat (ENT) physician. This documentation must explicitly state the medical diagnosis using a specific ICD-10 code and recommend MFT as the treatment.
Once the referral is secured, the patient must contact the insurance provider directly using the member services number. It is helpful to ask the representative specific, detailed questions, such as, “Do you cover CPT code 97112 when billed with ICD-10 code G47.33 for the treatment of mild obstructive sleep apnea?” The use of specific codes, provided by the MFT therapist, forces the insurer to check their system for a direct coverage policy. Document the date, time, name of the representative, and the reference number for the call.
The most important step is requesting a pre-determination or pre-authorization before the first session. This is a formal request sent to the insurer with the diagnosis, proposed treatment plan, and codes, asking for a written commitment on coverage. While not a guarantee of payment, a written confirmation significantly reduces the risk of a surprise denial after treatment begins. This process is the most reliable way to understand the financial responsibility before committing to the full course of therapy.
Alternative Payment and Financing Options
When insurance coverage is denied or unavailable, patients have several alternative avenues to finance MFT treatment. Many patients successfully use funds from a Health Savings Account (HSA) or a Flexible Spending Account (FSA) to pay for MFT. Since these are pre-tax dollars designated for eligible medical expenses and MFT addresses medical conditions, it generally qualifies, but patients should confirm with their plan administrator.
Many myofunctional therapists offer flexible payment plans or sliding scale options to make treatment more accessible. Patients should inquire about these options during the initial consultation. Some providers may also offer a “superbill,” which is a detailed invoice with the necessary codes that the patient can submit directly to their insurance company for potential out-of-network reimbursement.
Financing Alternatives
- Using HSA or FSA funds for payment.
- Flexible payment plans offered directly by the therapist.
- Submitting a superbill to the insurance company for potential out-of-network reimbursement.
- Utilizing limited benefits from certain dental riders or medical gap coverage.
Self-pay arrangements using HSA or FSA funds remain the most common and reliable alternative, especially when insurance coverage is completely unavailable.