Is Myofunctional Therapy Covered by Insurance? What to Ask, Which Codes to Know, and How to Get Reimbursed

Families exploring Orofacial Myofunctional Therapy (OMT) often share the same two worries: Will my insurance cover it, and is it really worth the cost? These questions matter because OMT is more than a trend. It is a structured program that retrains oral and facial muscles to improve breathing, swallowing, speech development, and overall health. Yet the pathway to reimbursement can be confusing.

In this article, we will break down the most common insurance questions, explain what insurers look for, and provide practical steps to improve your odds of coverage. Along the way, we will highlight why OMT is so effective in addressing mouth breathing and its ripple effects on health, from tongue posture to sleep quality.

Problem Identification – The Insurance Puzzle and Mouth Breathing Challenge

The first challenge families face is financial uncertainty. Unlike routine dental cleanings or standard medical visits, OMT sits at the crossroads of dentistry, speech therapy, and breathing retraining. That means insurance companies often struggle to classify it. Some plans recognize it as medically necessary, while others call it “alternative” or “out-of-network.”

At the same time, the underlying health problem driving many families to OMT—chronic mouth breathing—carries its own set of complications. Mouth breathing in children and adults is linked to:

• Narrow facial growth patterns and orthodontic relapses

• Speech development delays

• Poor tongue posture leading to swallowing difficulties

• Sleep-disordered breathing, snoring, or mild sleep apnea

• Increased risk of dry mouth, cavities, and gum issues

Without a clear insurance framework, families face not only health risks but also the stress of unpredictable bills.

Consequence Amplification – Why Leaving This Unsolved Hurts More Than the Wallet

If left untreated, mouth breathing is more than a bad habit. Over time, it reshapes oral structures, disrupts airflow, and affects a child’s growth and learning. Adults who continue to mouth breathe often report fatigue, headaches, and TMJ pain.

Financially, the absence of insurance coverage means families may delay or abandon treatment. This can have cascading effects:

• A child with delayed speech development may need years of extra school support.

• Sleep-disordered breathing can increase risks for hypertension or cardiovascular issues later in life.

• Orthodontic results may relapse, creating repeated, expensive treatment cycles.

The longer OMT is postponed, the more entrenched the problems become. Insurance confusion, therefore, does not just cause financial stress, it can keep families from seeking care that could improve health outcomes for life.

Solution Framework – Making Insurance Work for You

Understand What OMT Is in Insurance Language

Insurers do not cover “myofunctional therapy” as a category. Instead, they respond to medical necessity linked to specific diagnoses. That means coverage often depends on how your provider documents the issue. Commonly linked conditions include:

• Sleep-disordered breathing or sleep apnea

• TMJ dysfunction

• Swallowing disorders

• Speech or feeding challenges

Know the Codes

Two types of codes usually matter:

• ICD-10 codes identify the diagnosis (for example, “oropharyngeal dysphagia” or “sleep apnea”).

• CPT codes describe the therapy or evaluation performed.

Asking your therapist or referring physician which codes they use—and confirming whether your insurer recognizes them—is a critical first step.

Ask the Right Questions Before Starting

When calling your insurance company, be ready with this checklist:

• Does my plan cover therapy for swallowing, speech, or breathing disorders?

• Which CPT/ICD codes are recognized?

• Do I need a referral from a physician?

• Is pre-authorization required?

• Are services from a dental hygienist, speech-language pathologist, or other therapist covered?

Improve Your Odds of Reimbursement

• Letter of Medical Necessity: Ask your provider to write a letter describing the condition, its risks if untreated, and why OMT is the recommended therapy.

• Documentation: Keep symptom logs (snoring, headaches, school notes on speech issues).

• Collaborative Care Notes: Having supporting notes from orthodontists, ENTs, or sleep specialists strengthens your case.

Subtle Positioning – Where Primal Air Fits In

At Primal Air, OMT is never presented as a one-size-fits-all exercise program. Instead, it is customized to address the root causes of mouth breathing, incorrect tongue posture, and inefficient oral muscle function. Our approach includes:

• Breathing retraining: Incorporating Buteyko Breathing Techniques for long-term airway health.

• Multidisciplinary support: Collaborating with orthodontists, ENTs, and sleep physicians for holistic care.

• Clear communication: Helping patients navigate insurance questions, even when reimbursement requires persistence.

By pairing therapy expertise with practical support, we help families move past the barrier of financial uncertainty and focus on achieving healthier breathing, speech, and sleep.

The Bigger Picture: Why Insurance Matters for Mouth Breathing

Insurance coverage is not just about saving money. It is about making sure therapies like OMT are accessible for the children and adults who need them most. By advocating for yourself, using the right codes, and documenting symptoms carefully, you improve your chances of partial or full reimbursement.

And when therapy is accessible, the ripple effects are wide-ranging:

• Children develop clearer speech and healthier facial structures.

• Adults sleep better, feel more energized, and reduce TMJ pain.

• Families save money on repeated orthodontic or dental interventions.

FAQ Section (Based on People Also Ask)

Is myofunctional therapy covered by insurance? Sometimes, yes. It depends on your diagnosis, plan, and how your provider documents medical necessity. Ask your insurer about specific CPT and ICD codes.

How long does OMT take? Most programs involve daily exercises with therapist check-ins over weeks or months. Progress depends on consistency and severity of symptoms.

Does OMT help with sleep apnea or TMJ pain? Yes, research supports its role in improving tongue posture, reducing airway collapse, and easing muscle strain. It works best as part of a team approach.

Is mouth taping safe? Caution is needed. While some use it to encourage nasal breathing, risks include skin irritation or airway restriction. Always consult a healthcare provider.

What is the difference between Buteyko Breathing Techniques and OMT? OMT trains oral and facial muscles for proper function, while Buteyko Breathing Techniques target breathing patterns. Together, they complement each other.

Discover how to Identify Orofacial Myofunctional Disorders and how Orofacial Myofunctional Therapy can help - read our recent article here..