Pediatric sleep apnea — screening and billing

Check your patients’ insurance plans when billing for sleep apnea, and for younger patients, work with pediatricians to help the children and benefit your practice. 

Christine Taxin offers guidance on screening for childhood sleep apnea and billing

Orthodontics has become the first line of defense for children who suffer from obstructive sleep apnea (OSA) and TMD issues. Your collaboration with medical professionals is so important and lifesaving.

I have authored a book and talked about this previously, but having grandchildren has really opened my eyes to how important proper breathing is from the minute a child is born. Did you know that parents can buy a foot monitor for the baby to wear every night until 1-year-old? In the Owlet Dream App, a sensor in a little bootie called the “Dream Sock” monitors the baby’s live heart rate and oxygen level, and an alarm will go off if there are any issues.1 The peace of mind that parents can get from knowing the baby is sleeping soundly or needs you is amazing.

Because parents are already aware of possible breathing issues during babies’ sleep, collaborating with them may not be that difficult. It is also beneficial to have conversations with their pediatricians, since studies have shown that parents who have sleep or TMD issues have children with a higher risk.

The American Academy of Pediatrics Practice Guideline on diagnosis and management of childhood obstructive sleep apnea syndrome says that all children/adolescents should be screened for snoring.2

Are adult and childhood sleep apnea related?

The inheritance pattern of obstructive sleep apnea is unclear. Overall, the risk of developing this condition is about 50% greater for first-degree relatives (such as siblings or children) of affected individuals as compared to others.3

Pediatric obstructive sleep apnea and adult sleep apnea present differently. While adults usually have daytime sleepiness, children are more likely to have behavioral problems. The underlying cause in adults is often obesity, while in children the most common underlying condition is enlargement of the adenoids and tonsils. Early diagnosis and treatment are important to prevent complications that can affect children’s growth, cognitive development, and behavior.

Early diagnosis and treatment are important to prevent complications that can affect children’s growth, cognitive development, and behavior.

Offering pediatricians information

Collaborating with pediatricians in your area is the best way to encourage parents to refer to your office.

Did you know that after COVID-19, some doctors are not even looking in the oral cavity at all? I have recommended making a referral card for their patients. This list can help the pediatricians help the children and benefit your practice.

The front of card should have your information with information about why you can care for their children. The back of card can list the signs, symptoms, and risk factors of sleep-disordered breathing

During sleep, signs and symptoms of pediatric sleep apnea might include:4

  • Snoring
  • Pauses in breathing
  • Restless sleep
  • Snorting, coughing, or choking
  • Mouth breathing
  • Nighttime sweating
  • Bed-wetting
  • Sleep terrors

Infants and young children with obstructive sleep apnea do not always snore. They might just have disturbed sleep.

During the day, children with sleep apnea might:

  • Perform poorly in school
  • Have difficulty paying attention
  • Have learning problems
  • Have behavioral problems
  • Have poor weight gain
  • Be hyperactive

Besides obesity, other risk factors for pediatric sleep apnea include having:4

  • Down syndrome
  • Abnormalities in the skull or face
  • Cerebral palsy
  • Sickle cell disease
  • Neuromuscular disease
  • History of low birth weight
  • Family history of obstructive sleep apnea

How to file a claim with Aetna®

Aetna® considers oral appliances or functional orthopedic appliances medically necessary in the treatment of children with craniofacial anomalies with signs and symptoms of OSAS.

Aetna considers oral appliances or functional orthopedic appliances experimental and investigational for treatment of OSAS in otherwise healthy children. There is insufficient evidence that oral appliances or functional orthopedic appliances are effective in the treatment of OSAS in healthy children.

Note: Some medical plans, including new plans and non-grandfathered plans subject to Patient Protection and Affordable Care Act requirements, cover medically necessary orthodontic services for children and adolescents under a pediatric oral health benefit. Please check benefit plan descriptions. Under these plans, comprehensive orthodontic services are considered medically necessary for children and adolescents who have a severe handicapping malocclusion related to a medical condition such as:

  • Cleft palate or other congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services; or
  • Trauma involving the oral cavity and requiring surgical treatment in addition to orthodontic services; or
  • Skeletal anomaly involving maxillary and/or mandibular structures

To be considered medically necessary, orthodontic services must be needed to treat, correct, or ameliorate a medical defect or condition, and an essential part of an overall treatment plan developed by both the physician and the dentist in consultation with each other.

Orthodontic treatment is not considered medically necessary for dental conditions that are primarily cosmetic in nature or when self-esteem is the primary reason for treatment.

There is a form to evaluate the conditions that may or may not qualify patients for coverage of medically necessary orthodontic services.

Medically Necessary Orthodontia related to the Pediatric Dental Essential Benefit in the Affordable Care Act (ACA)

Comprehensive medically necessary orthodontic services are covered for members who have a severe handicapping malocclusion related to a medical condition. Establishment of medical necessity requires documentation to support the severe handicapping malocclusion and medical condition status. To qualify for coverage, a score of 42 points or greater on the Modified Salzmann Index is needed. Documentation must include a completed Salzmann Evaluation Form and a written report from the attending physician, pediatrician, or qualified medical specialist(s) treating the deformity/anomaly.

For your convenience, download the Salzmann Evaluation Form with instructions for completion.5 For more information on a plan that covers medical for orthodontic treatment visit, and read the entire contract. Learn how to use a Salzman Index so you are ready with the medical necessity issues needed for payment.

Rose Nierman offers her guidance on billing for sleep apnea in “Unlocking the code to medical insurance for oral appliances for OSA” at

Christine Taxin is the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. Prior to starting her own consulting company, Taxin served as an administrator of a critical care department at Mt. Sinai Hospital in New York City and managed an extensive multi-specialty dental practice in New York. With over 25 years’ experience as a practice management professional, she now provides private practice consulting services, delivers continuing education seminars for dental and medical professionals and serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for Maimonides Hospital.

Taxin is passionate about helping dental practices reach their highest potential and increase their profitability. In her consulting work, she focuses on helping practices strengthen their communication skills, their ability to work as a team and their capacity to set goals. As a provider of continuing dental education, Taxin has been a guest speaker for Henry Schein®, Kodak Dental, Sirona, and Goetze Dental. She has presented programs to the American Association of Dental Office Managers, the PennWell Dental Group, and the New York Academy of General Dentistry. The AGD has approved her company Links2Success as a national provider of PACE continuing education credits.

  1. Accessed July 26, 2022.
  2. Marcus CL, Brooks LJ, Davidson Ward S, et al. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. 2012;130(3):e714–e755.
  3. Medline Plus. Obstructive Sleep Apnea. Accessed July 26, 2022.
  4. Mayo Clinic. Pediatric obstructive sleep apnea. conditions/pediatric-sleep-apnea/symptoms-causes/syc-20376196. Accessed July 26, 2022.
  5. Salzmann Evaluation Form. ubmission-guidelines/salzmann-evaluation-form.html. Accessed July 26, 2022.
  6. Perikleous E, Steiropoulos P, Tzouvelekis A, et al. DNA methylation in pediatric obstructive sleep apnea: An overview of preliminary findings. Front Pediatr. 2018;6: 154.
  7. Pettitt-Schieber B, Tey CS, Nemeth J, Raol N. Echocardiographic findings in children with obstructive sleep apnea: A systematic review. Int J Pediatr Otorhinolaryngol. 2021; 145:110721.

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