Oral Appliances (MADs): Insurance & Providers Help?

I've done a search and read through the last several months' worth of posts mentioning oral appliances, but I figured a thread to get some fresh information would be helpful.

As I mentioned in another thread, my new sleep doc has referred me to an orthodontics doc for evaluation of an oral appliance. My untreated AHI was in the mid 30s, consisting almost entirely of hypopneas. My doc's theory is that I simply may be intolerant of pressure-based therapy, in which case an oral appliance could work well.

I have three major questions for folks familiar with these devices:
1) What luck have you had getting medical insurance to cover them? Blue Cross told me that they'd need to find out what procedure code the doc would use. All my DME-provided equipment has been fully covered, but oral appliances seem less cut and dried. I think the code for OSA is #E0486, but I don't know the ins and outs of the doctor-insurance relationship and what the likely outcomes are.
2) What success have you had? It seems that at least a couple of our posters have had good luck using a combination of oral appliance and xPAP therapy. Given my doc's theory, that would not be a viable combination for me. My untreated AHI is on the high side for oral appliances, but perhaps the fact that it is comprised mostly of hypopneas makes the prognosis better?
3) I also have has been diagnosed as asymptomatic TMJD. I use a cheap store-bought mouthguard to deal with my tooth grinding, which has been slowly wearing away my teeth. However, I have not had pain associated with the TMJD. I've read that the typical oral appliances for TMJD can make the latter worse. Has anyone had direct experience here? Are there styles of types of oral appliances that can successfully deal with both at the same?

I just have a bite guard made by my dentist... doesn't impact my AHI, doesn't make my TMJ worse (actually will make the pain go away when used).

I got a SomnoMed oral appliance and insurance covered it. But there was a fair amount of legwork before hand to make sure it was adequately covered. My insurance company had no In Network providers for sleep apnea oral appliances. But according to their coverage policy (page 4) [url]hhttp://www.cigna.com/customer_care/healthcare_ ... nt_svc.pdf[/url], it is a covered service if you meet specific requirements. So I had to make a request for network adequacy which took a while, but was approved for the initial consult. At the initial consult, I got all of the codes from the sleep dentist and again contacted Cigna to ensure it would be covered without hesitation (since I had to pay out of pocket and wait to be reimbursed). At the time of the fitting, I paid in full for the device and the dentist's office sent me a 1500 Health Insurance Claim form the next day. I faxed and mailed a cover letter with all the authorization numbers, the 1500 claim form, the referral from my neurologist, and a copy of my sleep study.

Despite the legwork up front, I ran into some problems with Cigna paying the claim, but they were eventually resolved. (Initially Cigna paid as an out of network claim even though I included the network adequacy. Then Cigna wanted to only pay a portion and claimed it was the Maximum Reimbursable Charge...but they had previously told me that there was not enough claims in my area for an MRC to apply to this service and that MRC didn't apply to network adequacy claims anyway. After several more calls and letters, I received a payment for Cigna's portion.)

With all that being said...the appliance has dramatically lowered my AHI from about 25 to near 0...but now I have about 25 RERAs. So I'm now using both the oral appliance and CPAP at a lower pressure. Still not feeling rested, and just had an appointment with the neurologist today and he's believe the mask is leaking, so tonight I start trying a few new things. I never had jaw pain before, but I have had a couple of times since getting my appliance. The dentist told me to stop the appliance for 5 days, then if I wasn't having any pain at all, start using it again.

One of the "wings" broke while the appliance was in place in my mouth and the lab apparently only covers the warranty for 90 days, despite the fact that if you go to the SomnoMed website it indicates they are covered for one year. This happened a couple of days before I was going to send it off to have permanent bumpers installed to make the opening a bit wider...total cost for both was about $175. Apparently certain labs that SomnoMed uses honor the 1 year warranty, but others only honor 90 days. Very disappointing and this would cause me to consider some other products over the the SomnoMed product.

In case anyone is curious, here's the breakdown of the codes and costs:
Consultation 99243 $95
Appliance E0486/NU $1885
Office Visit 99214 $295
Jaw X-Ray 70355 $95
Diagnosis 327.23

I had a night splint (heavy duty guard??) made by the dentist for TMJ . I now use it every night with my full face mask and the jaw pain has gone and I am now longer wearing my teeth away from grinding in my sleep.

I saw the orthodontist today, and he said that while I look like a good candidate for an oral appliance, insurance (BCBS) is very likely to deny my claim because my untreated AHI is too high (36). Has anyone else run into this snag and, even more important, how did you deal with it? I have my new sleep doc lined up to right a letter of medical necessity, documenting the reasons why I've failed with xPAP therapy, but I'd welcome more ideas and input.

P.S. He thinks I don't have TMJD and that I simply am a grinder. And for that reason, he thinks the oral appliance ought to be nothing but good for me.

Here's the BCBS of Tennessee coverage policy for Sleep Apnea. According to their policy, oral appliances are not covered for severe sleep apnea (>30 AHI).

Certainly worth asking the sleep dentist and doctor request coverage if they think it will help.

http://medicalpolicy.hcsc.net/medicalpo ... gery#hlink

BrianinTN wrote:I saw the orthodontist today, and he said that while I look like a good candidate for an oral appliance, insurance (BCBS) is very likely to deny my claim because my untreated AHI is too high (36). Has anyone else run into this snag and, even more important, how did you deal with it? I have my new sleep doc lined up to right a letter of medical necessity, documenting the reasons why I've failed with xPAP therapy, but I'd welcome more ideas and input.

P.S. He thinks I don't have TMJD and that I simply am a grinder. And for that reason, he thinks the oral appliance ought to be nothing but good for me.

BrianinTN wrote:I saw the orthodontist today, and he said that while I look like a good candidate for an oral appliance, insurance (BCBS) is very likely to deny my claim because my untreated AHI is too high (36). Has anyone else run into this snag and, even more important, how did you deal with it? I have my new sleep doc lined up to right a letter of medical necessity, documenting the reasons why I've failed with xPAP therapy, but I'd welcome more ideas and input.

P.S. He thinks I don't have TMJD and that I simply am a grinder. And for that reason, he thinks the oral appliance ought to be nothing but good for me.

Hi Brian

Are you talking about a Mandibular Advancement Device ? If so -

An acquaintance of mine has had success with a MAD with an original AHi of 40, though I understand that this is not the norm.

I would be considering a MAD combined with any sleep positional therapy that suits your personal obstructive sleep apnea.

It also might be worthwhile checking it out any how, because if an $8-00 cervical collar will do the job, why bother with all the rest ?

cheers

Mars

Yup, that's it. My untreated AHI was almost entirely hypopneas, so I don't know if that affects the prognosis or not.

BrianinTN,

I'd ask the sleep doc who referred you to the sleep dentist/orthodontist and the sleep dentist to jointly ask your insurance for prior approval for the oral device. Your MD sleep doc is willing to certify that xPAP is simply not working for you IN SPITE of your being compliant---i.e. you've USED the xPAP machine for more than 4 hours a day consistently for <so many weeks or months>, but your daytime functioning is NOT improving. (What about your AHI? If I recall, it's not gotten down to less than 5 either, right?) So---your request for pre-authorization for the oral appliance is NOT because you simply don't want to sleep with a mask or that you're unwilling to sleep with a mask. Rather, it's because you've made a good faith, long term effort to make xPAP work and your MD sleep doc is saying that you are one of the few who just doesn't respond well enough to xPAP for it to be worth the effort. Ergo, a less effective treatment (the oral appliance) is better for your severe OSA than NO treatment at all. That's what the sleep doc and the sleep dentist have to stress in their joint request for prior approval for the device.

And if the request for prior approval is DENIED, then you should appeal the decision with the help of both the doctor and the dentist.

I thought it would be good to post an update here and ask for a second round of suggestions and advice.

I've spent hours and hours on the phone with BCBS. The long story short is that:
* As the orthodontist is not in the BCBS network, it would be an out-of-network claim, which means that I'm facing a $500 deductible and 20% of the remainder. So, best case scenario if they decide to cove it is that I'm paying $660 of the $1300.
* Because of the nature of my PPO, BCBS absolutely will not do any type of pre-authorization or pre-certification. It's a roll of the dice as to whether or not they'd even decide it's "medically necessary," and no way for me to get an answer ahead of time.
* I tried finding out if an in-network orthodontics provider exists. There were no hits on BCBS's online tool, and calling them resulted in nothing too -- both in my area or nationally. Clearly, "orthodontics," despite being searchable in the BCBS database, doesn't result in any in-network hits.

I really would rather not be out a ton of money for something not even guaranteed to work. So here are my questions.
1) Is there another speciality besides "orthodontics" that might result in an in-network provider who could provide an oral appliance? (The woman I spoke with suggested trying "oral surgeons," but it too turned up nothing.) If yes, is that a bad idea?
2) If not, is this likely to be better when and if I get dental insurance? Or is this destined to be a finger-pointing game, with dental insurance saying this is a medical issue and medical insurance saying that orthodontics isn't covered?
3) The procedure code, I've been told several times, comes under my DME benefits. But that seems quirky to me, since this isn't a plug-and-play device and requires custom fit.

Any suggestions to help me find my way out of this morass would be most welcome.

Josh, I know you've mentioned that you've filed for a Network Adequacy Exception. In searching online, I've found no other references to that, and haven't seen anything in my BCBS policy text to refer to it. (In fact, Googling the page turns up your post on the front page - not many hits!) Do you have a suggestion about how you would proceed with trying to find out whether that's possible?

Hi, I'd start by asking for a supervisor, explaining the situation, and asking for his or her help to find a qualified In Network Provider. If that doesn't work, I'd ask for my employer's help and file a written appeal if needed.

Here's some info I found from Anthem about how they handle the process... http://www.anthem.com/wps/portal/ahppro ... O#P30_1958

Here's some more documents that are geared towards Sleep Dentists, but they have TONS of information and should be very helpful:
http://www.somnomed.com/files/files/US% ... %20OSA.pdf
http://www.comfortacrylics.com/applianc ... manual.pdf
http://www.nti-tss.com/DDS-Billing/Oral ... sement.pdf

BrianinTN wrote:The procedure code, I've been told several times, comes under my DME benefits. But that seems quirky to me, since this isn't a plug-and-play device and requires custom fit.

It's not all that quirky. DME stands for Durable Medical Equipment, so any such equipment could be covered under the DME benefits. And, the fitting of such devices can also fall under DME benefits, without being so quirky, either. I had an ankle/ foot orthotic (AFO) for quite awhile. The AFO itself was covered under my DME benefits as was all the stuff that went into getting it made special, just for me. My recollection is a bit hazy, but I think it was similar to a casting procedure, to get a mould for my specific foot, ankle, and lower leg.

BrianinTN wrote:Any suggestions to help me find my way out of this morass would be most welcome.

I have a great recipe for morasses cookies. Would that help? (Probably not because then you would want to eat the cookies, which would get more morass into you rather than get you out of the morass.)

Deborah

Deborah