Avoid Medical Denials by Knowing these Trends

by Rose Nierman and Courtney Snow

Medical policies change. That is the only thing that can always be counted on in the fickle world of medical billing for Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA). To remain efficient and successful in medical billing for OAT for OSA, it’s critical to be aware of new trends.

Medical insurers maintain coverage policies that provide criteria a patient must meet to be eligible for coverage. However, coverage criteria don’t remain static. Coverage policies are regularly reviewed and updated. Fortunately, coverage policies are typically publicly accessible on the medical insurer’s website.

Some criteria that are universal amongst medical insurers for patients to be eligible for coverage for OAT for OSA:

• Must be diagnosed with OSA with a sleep study
• Must have a prescription/written order from a physician

And a few common criteria:

• If severe OSA, must be deemed intolerant/non-compliant or contraindicated for Positive Airway Pressure (PAP) therapy.
• If mild OSA, must exhibit at least one of the following comorbidities: history of stroke, hypertension, ischemic heart disease, impaired cognition, mood disorders/insomnia, excessive daytime sleepiness, or significant oxygen desaturation.

So, what’s new? It’s not TikTok, but here are some trends you should be aware of:

• Proof of delivery is no longer only for Medicare. Increasingly, private/commercial insurers are requiring a proof of delivery form signed by the patient.
• Notes from a visit with a physician before the sleep study or beginning Also, not just for Medicare anymore!
• Use of an oral appliance that is PDAC approved for HCPCS code E0486. This is yet another rule that is not just for Medicare anymore. Increasing numbers of private/commercial insurers require the use of specific appliances found on the PDAC list for E0486.
• Sleep study within one year prior to delivery of oral sleep appliance. While some medical insurers continue to accept sleep studies 2-3 years old, the 1-year trend is undoubtedly rising.
• Documentation of absence of TMJ disorder and significant/active periodontal disease. Include this information in the objective section of your SOAP notes from the oral exam.
• PAP therapy intolerance/non-compliance or refusal documented by a physician. In the past, an affidavit indicating why the patient cannot tolerate PAP therapy signed by the patient would suffice. Many insurers are now requiring this to be in the physician’s notes instead.

Not all medical insurers will require all the items discussed in this article. However, it’s crucial to be familiar with the trends and regularly review local coverage policies for medical insurers in your region.

At Nierman Practice Management, we regularly review these coverage policies, alert our clients and continuing education seminar attendees of significant changes & trends, and update the DentalWriter software based on new trends. This ensures your software is compliant and you’re hip to all the current trends in dental sleep medicine.