Medical Management of Pediatric Sleep Apnea and TMD in Your Dental Office

A Beginner’s Guide
by Christine Taxin
Sleep apnea is a growing problem for America’s children and teenagers. Researchers from the Cleveland Clinic have suggested that between 1% and 10% of U.S. pediatric patients suffer from obstructive sleep apnea (OSA), with devastating results. Sleep apnea impacts children’s endocrine systems, their growth, their behavior, their ability to learn, and their ability to resist disease. It is more common in children who suffer from obesity and children under the age of 9, but children of all ages and BMIs are at risk. Researchers have also discovered that untreated OSA can lead to TMD in up to 73% of patients with OSA. The ADA’s new SRBD Policy Statement includes an excellent point about dentist’s responsibility: In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.
Does your child snore? Does your child show other signs of disturbed sleep: long pauses in breathing, much tossing and turning in the bed, chronic mouth breathing during sleep, night sweats (owing to increased effort to breathe)? All these, and especially the snoring, are possible signs of sleep apnea, which is commoner among children than is generally recognized. It’s estimated than 1 to 4 percent of children suffer from sleep apnea, many of them being between 2 and 8 years old. No part of medicine/ dentistry can do this alone. Sleep physicians have no clinical role in growth and development, orthodontists don’t diagnose SRBD, families require special behavioral skills, and general dentists need to know which specialists they can refer their at-risk children to. General dentists, as a whole, see more children more frequently than any other subset of medicine and dentistry for preventive services. Talking with families about SRBD opens the door to lifetime health. The treatment window for affecting the growth of the airway is short, with 90% complete before the child reaches puberty. Identifying at-risk children early enough to intervene and set them on a path of life yime health is going to be dentistry’s greatest contribution to community health ever. Furthermore, while there is a possibility that affected children will “grow out of” their sleep disorders, the evidence is steadily growing that untreated pediatric sleep disorders including sleep apnea can wreak a heavy toll while they persist. Studies have suggested that as many as 25 percent of children diagnosed with attention deficit hyperactivity disorder may actually have symptoms of obstructive sleep apnea and that much of their learning difficulty and behavior problems can be the consequence of chronic fragmented sleep. Bed-wetting, sleep-walking, retarded growth, other hormonal and metabolic problems, even failure to thrive can be related to sleep apnea. Some researchers have charted a specific impact of sleep disordered breathing on “executive functions” of the brain: cognitive flexibility, self-monitoring, planning, organization, and self-regulation of affect and arousal. Several recent studies show a strong association between pediatric sleep disorders and childhood obesity. Judith Owens, M.D., director of sleep medicine at the National Children&’s Medical Center in Washington, DC, who is a member of the ASAA board of directors, believes that adequate healthy sleep is as important as proper diet and sufficient exercise in preventing childhood obesity.

Screening for Sleep Apnea in Pediatric Patients

Before screening a pediatric patient for sleep apnea, ask parents for a list of all current medications and the contact information for any doctors or therapists involved in the treatment of the child. This is very important since pediatric sleep apnea is often misdiagnosed as ADHD, since poor sleep severely impacts a child’s ability to pay attention and exercise self-control.
Use the following questions to pre-screen for OSA risk factors in your pediatric patients.

  • Does the child sleepwalk?
  • Does the child urinate in their sleep?
  • Does the child sleep in class?
  • Does the child act out in class or at home?
  • Does the child tend to breathe with their mouth open?
  • Does the child have breathing pauses during sleep?
  • Does the child experience daytime sleepiness?
  • Does the child have difficulty with concentration?
  • Does the child have a poor attention span?
  • Does the child have behavioral issues?
  • Does the child show poor performance at school?
  • Does the child wet their bed?

If a patient displays any of these risk factors, you should administer the Orthodontic Service Salesman Evaluation Index. This evaluation is essential if you plan to bill insurance for any treatments for OSA or TMD. It allows the dentist to make to diagnosis the child, bring in their other provides to collaborate with on the case. They find that many children who have sleep/OSA is a side effect of the airway restriction that dentists CAN diagnose. Most treatments are covered under medical for appliance therapy since we are opening the airway for the child to grow.

Documentation for Insurance

Insurers require specific forms of documentation and imaging before they will reimburse for appliances that treat pediatric OSA or TMD. In addition to the Orthodontic Service Salzmann evaluation index, you’ll need to provide detailed notes about the objectives for any treatment or testing.

The Salzmann evaluation index is the only test accepted by insurance to pay for treatment. It is not the best, but the only scoring system at this time. TIP: All of the child’s doctors and therapists must be on-board with this treatment option in order for insurance to pay.

These notes should include:

  • A list of the symptoms reported by the guardian and those observed in office
  • References to any comorbidities that have been found to cause or be caused by OSA (for instance: ADHD, cardiac issues, obesity, diabetes, daytime sleepiness)
  • The type of sleep study ordered (include relevant codes) and the reason for ordering the test
  • The Current treatment plan for the patient
  • The patient’s history of past treatments both for the sleep issue and any comorbidities
  • If a CPAP has been tried, a notation of when and why its use failed
  • A copy of results from the sleep study
  • A copy of the questionnaire about sleep habits and the Salzmann test (Must score at least 42 points)
  • Written reports from the pediatrician, including letters of support for this treatment option. All of the child’s doctors and therapists must be on-board with this treatment option in order for insurance to pay.

Some of these requirements may seem repetitive or redundant. However, when you’re dealing with medical insurance, it is important to make documentation as complete as possible. This will help the insurer in evaluating the claim promptly and reduce the number of hours your staff needs to spend dealing with the claim in the long-term.

Dealing with Medical Insurers

Once you’ve compiled the documentation, you’re ready to submit the claim. Each insurer has different requirements for the treatment of sleep apnea in children, what constitutes medical necessity and how to determine the severity of a given case. You should refer to these portions of the policy when submitting your claim. Remember, you are trying to make a case that a particular child’s disease and treatment should be covered by the plan.
Be prepared to receive a ‘no’ answer on your first submissions. Insurers initially deny 61% of claims that are eventually paid. They are trying to get you to give up on the claim, but you shouldn’t take ‘no’ for an answer.
For instance, there is a high rate of comorbidity between OSA and TMD. If the insurer finds that OSA treatment is not medically necessary, you may be able to get the child appropriate treatment by submitting via the TMD route. Reversible intra-oral appliances can be considered medical treatment for TMD when there is evidence of clinically significant masticatory impairment with documented pain and or loss of function. The child must suffer this pain for 6-8 months before the application of appliance. You cannot reference bruxism or sports guards in the documentation, as these are considered dental, not medical, needs. All TMD treatment requires preauthorization.

Too Complicated? Get Help.

Do the procedures for medical billing for pediatric OSA appliances seem too complicated? You and your staff can learn to bill insurance and help patients avoid unnecessary surgeries. Links2Success can help your team get the education they need to work with medical insurers so that you can help these pediatric patients.

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