Oral Appliances for the Treatment of Obstructive Sleep Apnea - (A016)

Custom-fit (and covered prefabricated) oral appliances for obstructive sleep apnea are covered when a sleep study shows AHI/RDI/REI ≥15, or ≥5–<15 with documented symptoms or qualifying comorbidities, with replacements allowed if lost/damaged or more than 5 years old; pediatric coverage is limited to children with craniofacial anomalies and OSA signs/symptoms. Coverage requires documentation of a minimum one‑month PAP trial showing intolerance or lack of benefit (unless PAP is contraindicated) or patient preference with AHI/RDI/REI <30, a physician face‑to‑face order after review of the sleep study, and provision/follow‑up by a licensed dentist (DDS/DMD).

"Custom fit oral appliances are indicated when all of the following criteria are met:"

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