By Peter Blais, RPSGT
Most payors will reimburse for an oral appliance when a patient is intolerant to CPAP (continuous positive airway pressure) therapy, says Rose Nierman, founder and CEO of Nierman Practice Management. So for patients who have tried and failed CPAP, and even for those who have refused CPAP, many medical insurance companies will pay for an alternative to have the obstructive sleep apnea treated.
The medical insurer will likely request a CPAP intolerance affidavit that is signed by the patient, Nierman says. The affidavit will explain why CPAP was unsuccessful, which may include CPAP mask leaks, discomfort from headgear, interrupted sleep, claustrophobic associations, or disruption of the bed partner’s sleep.
Most medical policies also indicate that the patient may refuse or decline CPAP therapy and then be eligible for an oral appliance, Rose says.
For patients who’ve failed UPPP surgery (uvulopalatopharyngoplasty), Nierman adds that having an oral appliance paid for at this juncture is frequently doable as well. “I see many cases where the medical insurance reimburses for an oral appliance following failed UPPP surgery,” Nierman tells Dental Sleep Corner. “During the preauthorization or claims process, it’s important to send documentation, such as the physician’s prescription for an oral appliance. Most payors will also request the dentist’s notes indicating that the patient is a candidate for an oral appliance with a copy of the most recent sleep study.”
Nierman
Should the first attempt to obtain coverage fail because of a possible misunderstanding, Nierman prescribes to the old adage: “If at first you don’t succeed, try, try again.” She says, “You should definitely re-apply for coverage whether it’s a preauthorization or a claim for completed services that is denied. Insurers do have to tell the beneficiary why a claim was denied and outline the appeal process.
“There are both internal and external reviews available during the appeal process. Send a written appeal based on the reason for the denial. Frequently, additional documentation of medical necessity or a summary of past failed treatments is all that is needed to clear up any misunderstandings.”
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