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Coverage criteria policies

Oral appliances for sleep disorders

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for oral appliances for sleep disorders.

A DME Medical Policy Review form for Medical Necessity must be submitted by the ordering provider if the clinical records submitted do not contain all the required information.


Oral appliances for sleep disorders are generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

  1. The member must have a preliminary diagnosis of Obstructive Sleep Apnea (OSA) or Upper Airway Resistance Syndrome (UARS) confirmed by either polysomnography or by a covered home sleep test (HST). The oral appliance must be necessary for the care or treatment of OSA or UARS.
  2. An Oral appliance to treat mild (AHI of 5-15) or moderate (AHI of 15-30) OSA (see below for definitions) is covered for either of the following:
    1. Member does not respond to, or is not an appropriate candidate for treatment with behavioral measures such as weight loss or sleep position change; or
    2. Member prefers an oral appliance to CPAP, or has not responded to nasal CPAP, or is not an appropriate candidate for CPAP
  3. An Oral appliance to treat severe OSA (AHI of more than 30) (see below for definition) is covered when both the following are met:
    1. Sleep Specialist has evaluated the member and recommends an oral appliance; and
    2. Member is intolerant of, or refuses treatment with CPAP
  4. Benefit is limited to one permanent appliance every three years.
  5. Benefit is limited to either oral appliances or CPAP. Coverage for both would require documentation from physician stating the medical reasons for both types of treatment to be administered at the same time.
  6. Oral appliances for members under the age of 18 will be covered for the treatment of OSA when they have been diagnosed by polysomnography and an oral appliance is ordered by a sleep specialist (see below for definition).

Indications that are not covered

  1. Oral appliances for the treatment of snoring.
  2. Non-prescription, over the counter oral appliances, because their effectiveness has not been established.
  3. Replacement or repair of any covered items, if the items are:
    1. Damaged or destroyed by member misuse, abuse or carelessness; or
    2. Lost; or
    3. Stolen


Apnea/Hypopnea Index (AHI) is an average that represents the combined number of apneas and hypopneas that occur per hour of sleep:

  • None/Minimal Obstructive Sleep Apnea (OSA) is defined as an AHI of less than 5
  • Mild Obstructive Sleep Apnea (OSA) is defined as an AHI of 5-15
  • Moderate Obstructive Sleep Apnea (OSA) is defined as an AHI of 15-30
  • Severe Obstructive Sleep Apnea (OSA) is defined as an AHI greater than 30

Obstructive sleep apnea (OSA) is a result of an obstructed (blocked) airway. The breathing muscles continue to move the chest but, because of the obstruction, air is not able to move in or out of the lungs. OSA is characterized by repeated pauses in breathing during sleep, which lead to the fragmentation of sleep and decreases in the body's oxygen.

Oral appliances are custom molded devices used to treat obstructive sleep apnea. These devices help keep the airway open during sleep by bringing the jaw forward, elevating the soft palate, or retaining the tongue.

Other terms for oral appliances include: mandibular repositioning devices, tongue retaining devices, nocturnal airway patency appliances, dental guards, snore guards and orthotic appliances.

Polysomnogram measures bodily functions during sleep and is done in-lab at a sleep center. Some of the measurements taken may include: brain waves, heart rate, nasal and oral breathing, sleep position, and levels of oxygen saturation.

Respiratory disturbance index (RDI) is defined as the average number of respiratory disturbances (obstructive apneas, hypopneas, and respiratory event–related arousals per hour.

Sleep specialist is defined as a physician who is Board eligible or certified by the American Board of Sleep Medicine, or a pulmonologist or neurologist whose residency/fellowship included specialized training in sleep disorders and whose practice comprises at least 25% of sleep medicine. (Nurse Practitioners and Physicians Assistants who are directly supervised by a Sleep Specialist physician may also prescribe an oral appliance).

Supportive clinical symptoms for OSA and UARS include:

  • awakenings in which member experiences sensations of choking or gasping
  • excessive daytime sleepiness
  • restless and non-refreshing sleep
  • loud snoring
  • morning headaches

Upper airway resistance syndrome (UARS) is a condition in which a narrowed upper airway does not cause identified apneas. Because the upper airway is narrowed, the muscles have to work harder to move air in and out of the lungs. This increased workload leads to day and nighttime sleep disturbances.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.




Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment


Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.


  1. Aurora, R. N., Zak, R. S., Karippot, A., Lamm, C. I., Morgenthaler, T. I., Auerbach, S. H., ... Ramar, K. (2011). Practice parameters for the respiratory indications for polysomnography in children. American Academy of Sleep Medicine. SLEEP34(3), 379-388.
  2. Cistulli, P., Oral appliances in treatment of obstructive sleep apnea in adults. In: UpToDate, Collop, N. & Finley, G. (Eds). UpToDate, Waltham, MA. (Accessed on April 20, 2018.)
  3. Epstein, L. J., Kristo, D., Strollo, P. J., Friedman, N., Malhotra, A., Patil, S. P. … Weinstein, M. D. Clinical guideline for the evaluation, management and long term care of obstructive sleep apnea in adults. American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, 5(3), 263-276.
  4. Hayes, Inc. Hayes Medical Technology Directory Report. Mandibular Advancement Devices for Sleep Apnea. Landale, PA: Hayes, Inc.; August 2010. Reviewed July 2014/Archived 2015.
  5. Kushida, C.A., Morgenthaler, T. I., Littner, M. R., Alessi, C. A., Bailey, D. Coleman, J. Jr., … Pancer, J. P. (2006).
  6. parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: An update for 2005. American Academy of Sleep Medicine Report, SLEEP, 29(2), 240-243.
  7. Ramar, K., Dort, L. C., , Katz, S. G., Lettieri, C. J., Harrod, C. G., Thomas, S. M., & Chervin, R. D. (2015). Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: An update for 2015. American Academy of Sleep Medicine and America Academy of Dental Sleep Medicine. Journal of Clinical Sleep Medicine, 11(7), 773-827.
  8. Randerath, W. J., Verbraecken, J., Andreas, S., Bettega, G., Boudewyns, A., Hamans, E., … Fietze, I. (2011). Non-CPAP therapies in obstructive sleep apnoea. European Respiratory Society. European Respiratory Journal, 37, 1000–1028. doi: 10.1183/09031936.00099710

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Policy activity

  • 01/01/1994 - Date of origin
  • 04/01/2018 - Effective date
Review date
  • 04/2018
Revision date
  • 12/23/2015

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