Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea 
Treatment: Code E0486 - NU Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment 

The insurer denied coverage for code E0486 - NU Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment. The denial is overturned. 

This is a male patient who has mild obstructive sleep apnea (OSA) as demonstrated on a home sleep test (HST). The patient has expressed a preference to use an oral appliance (OA) rather than continuous positive airway pressure (CPAP). The patient has no stated contraindications for the use of OAs such as issues with temporomandibular joint (TMJ) syndrome or dental implants. Based on the patient's clinical history and results of the HST, the patient is a good candidate for the use of an OA. 

As noted in Up to Date based on the AASM "OSA is defined as either an obstructive respiratory disturbance index (RDI) greater than or equal to 15 events per hour with or without symptoms, or an obstructive RDI between 5 and 14 events per hour that is accompanied by any of the following: sleepiness, nonrestorative sleep, fatigue". This patient's findings are consistent with this definition. 

A clinical practice guideline by the American Academy of Sleep Medicine states that oral
appliance (OA) is generally as effective as continuous positive airway pressure (CPAP) across all levels of OSA severity. There was no significant difference between OAs and CPAP in the percentage of mild obstructive sleep apnea (OSA) patients achieving their target AHI/RDI/ REI (< 5, < 10, > 50% reduction) after treatment. Thus, the expert panel recommends that sleep physicians use OAs for adult patients with OSA who are intolerant of CPAP therapy or prefer alternate therapy. (1) A consensus report by the American Academy of Dental Sleep Medicine states that OAs are indicated for patients with mild to moderate OSA and primary snoring. (2) The device in question also has FDA approval for the treatment of obstructive sleep apnea (OSA). (3)   

Up to Date in a discussion regarding oral appliances states "For patients with mild or moderate OSA who decline or fail to adhere to positive airway pressure therapy, an oral appliance is a reasonable alternative to positive airway pressure. This is based upon the recognition that while positive airway pressure is generally more effective than an oral appliance at normalizing respiratory events and oxyhemoglobin desaturation episodes during sleep [51,87], most patients prefer an oral appliance, adherence is an essential aspect of successful treatment, both modalities are effective compared to no treatment or a sham treatment, and both modalities have a similar effect on symptoms and quality of life." 

Based on the above, the medical necessity for code E0486 - NU Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment for date of service is substantiated. The insurer's denial should be overturned.