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Imagn Billing Featured Case: Oral Appliance

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In this example Imagn Billing case you will see how a dental office in Washington successfully billed for a sleep appliance and even got a gap exception approved. Our Imagn Billing team processed this claim on 08/19/2020 to Cigna insurance and it was paid on 09/29/2020.

The 32-year-old male patient presented for a routine hygiene appointment and his sleep screening showed symptoms including daytime tiredness and snoring. The dentist felt these symptoms could be indicative of a sleep disorder and recommended the patient be tested. The patient agreed and tested using a home sleep test. The test was interpreted by a board-certified sleep specialist who diagnosed him with Moderate Obstructive Sleep Apnea. The specialist recommended an oral appliance and the dentist agreed that the patient is an ideal candidate for treatment.  

Proving Medical Necessity 

Having this diagnosis from the MD makes this an ideal case to bill medical insurance.  The dental office determined that this case was medically necessary by defining how the chief complaint of daytime tiredness and snoring affected the rest of the body. Which was diagnosed as obstructive sleep apnea by a board-certified sleep specialist and as a result could be treated with a dental device.

Billing Medical Insurance 

The practice collected all required documentation, which included the sleep test results with interpretation, a written prescription for an oral appliance, clinical SOAP notes and a signed CPAP Affidavit. After completing the verification of benefits, it was determined that coverage was available after the deductible is satisfied. Pre-Authorization was required and was completed with approval along with a Gap exception.

View Original EOB
Procedure Diagnosis Charged Paid
E0486 G47.33 $3,750 $1,992.16

Dental Comparison

Procedure Diagnosis Charged Patient Portion
No Coverage Available No Coverage Available No Coverage Available $3,750.00

Without medical insurance’s contribution, the patient would have paid out of pocket between $3750 and $3111.84.  Medical insurance saved the patient approximately $2000, whereas dental insurance had no coverage at all. The patient also completely satisfied their deductible, so moving forward they will have less out of pocket expenses if a healthcare issue arises. 

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