Medicare and Tricare coverage for oral appliances

Medicare, Tricare and other government insurances should cover oral appliances but that does not mean it will be easy. Medicare requires dentists form a DME, then pays poorly, See question from Eduardo received 8/31/12

Question from Eduardo: Why has my dentist taken so long to see if I can get an oral appliance for sleep apnea and snoring. Also I need to know if most of your Dentist take medicare and Tricare for life, I need to get something going.The doctor I have is taking too long I aplied back in May 2012 and still nothing

Dr Shapira response: Unfortunately while covered by medicare most docs won't take it. Medicare requires that an the dentist has a DME and choice of appliances is very limited. I do not accept medicare and have opted out and medicare patients pay my fee. My office is near great lake navak base but tricare has never paid for an appliance.

The good news is that CPAP is very successful if you can tolerate it. If not you must be proactive with Tricare and/or medicare that they find you a provider.

My suggestion is just to pay out of pocket if you can afford it otherwise get on CPAP while waiting for approval.

The good news about untreated sleep apnea is that it can kill you......the bad news is that it can cause a stroke!

IRA L SHAPIRA DDS, D,ABDSM, D,AAPM, FICCMO

There are several questions when it comes to Medicare coverage. First is whether medicare can afford to take on the cost of oral appliances considering the majority of seniors have some sleep disordered breathing. The requirement that dentists form DME's for each office is ridiculous, expensive and cumbersome. The proper approach is for Medicare to contract with Medicare approved labs that make appliances for sleep apnea and to pay the lab cost directly to the manufacturer. The dentist professional fee should be governed by standard Medicare B pay codes and fees. The alternative is that dentists opt out and patients make private arrangements for professional services.

Medicare should cover appliance manufacturers for the appliance based on specific appliances. My personal feelings is that there should be a minimal qualification of the dentist to have medicare cover the lab costs. A good idea might be to use diplomate status in the AADSM. Dentists who do not meet requirements would just do private contracts for the full amount. The dentist would not need to participate in Medicare but could if they desired.

Labs would have to meet Medicare standards for coverage, a difficult to define and ever changing target. Because labs serve thousands of dentists it would be financially effective.

It should be clearly understood that medicare would limit the number of appliance types.

In Illinois, Southern Wisconsin I personally treat patients with medicare after an opt out is signed. Patients who opt out of medicare can use the appliance of their choosing but must pay for it themselves.

Wisconsin Sleep Apnea Treatment: Oral Appliances are a comfortable alternative to CPAP, BiPAP or A-PAP

Treatment of sleep apnea is vital to the health and welfare of patients diagnosed with sleep apnea. CPAP treatment was once the only treatment offered to most patient. This is no longer the case. Dental Sleep Medicine ofers comfortable oral appliances as a comfortable alternative to CPAP.

Most sleep physicians follow the AASM guidline and offer oral appliance therapy as a treatment choice. Some sleep physicians have not kept up with the research and are not aware that recent studies have shown that properly titrated cpap oral appliances can be as effective as cpa.

60% of all patients who try cpap cannot tolerate and discontinue treatment while 90-95% of patients are successful with oral appliance therapy. The majority of patients offered a choice prefer oral appliance therapy to cpap and most insurance companies now cover oral appliance therapy.

Coverage of sleep apnea treatment saves insurance companies money by reducing heart attacks and strokes, hypertension, aiding in diabetes treatment and reducing motor vehicle and work-place accidents.

Employers have found that employees who have had effective sleep apnea treatment have higher output, lower medical expenses, and fewer workplace accidents and worker compensation claims.

Some sleep physicians continue to bad mouth oral appliance out of ignorance or due to bad experiences with untrained dentists providing poor quality treatment in the past.

Many dentists do not understand the importance of follow-up polysomnography in all patients. Failure to follow proper protocols can put patients at risk.

Other physicians have financial intrests in DME companies and are loathe to lose the income sales of cpap and cpap supplies generate.

I provide Dental Sleep Medicine treatment with oral appliances to patiens in Southeast Wisconsin including Lake Geneva, Kenosha, Racine and Milwaukee. I am certified in Dental Sleep Medicine and a Diplomate of the American Board of Dental Sleep Medicine. I am a former Asistant Professor at Rush Medicak Schools sleep center and have over 25 years successfully treating sleep apnea with oral appliances.

I NEED HELP WITH MY CPAP MASK!

TOM:

I NEED HELP WITH MY CPAP MASK. I HAVE TRIED SEVERAL BUT HAVE CONTINUOUS PROBLEMS WITH LEAKS AND DRY EYES. THE NASAL PILLOWS WERE AN IMPROVEMENT OVER THE NASAL MASK FOR A WHILE BUT THE QUIT WORKING. I AM NOW USING A FULL FACE MASK WHICK IS OK ON SOME NIGHTS BUT I FEEL WORSE THAN I DID BEFORE CPAP. MY DOCTOR TOLD ME I AM NOT A CANDIDATE FOR AN ORAL APPLIANCE BECAUSE MY APNEA IS SEVERE. I QUIT BREATHING 50 TIMES AN HOUR. I USUALLY MANAGE TO GET AN HOUR OF TWO OF SLEEP BEFORE I GIVE UP ON IT. HELP!

DR SHAPIRA RESPONSE: Tom, I understand your frustration and I commend you on your efforts to comply with treatment. 60% of patients give up on CPAP and that is very dangerous. I suggest that you get a copy of your sleep study and contact a dentist who is experienced in treating sleep apnea. Oral appliances are a comfortable alternative to CPAP and are a first line choice for treatment of mild to moderate sleep apnea according to the American Academy of Sleep Medicine. They are an acceptable alternative to CPAP for severe sleep apnea when patients do not tolerate or want CPAP treatment.

I advise you to continue to use your CPAP with your appliance until after a sleep study show the it is effective. Recent studies have shown that properly titrated appliances are as effective as CPAP and can be used for severe apnea in many patients. It is vital that a titration sleep study be done to find the ideal position to maintain an open airway.

An appliance that is not properly adjusted is a "POP" or piece of plastic not an effective treatment unless your problem is a congenital lack of plastic.

I frequently see patients who say they tried an appliance and it didn't work. This is usually because the dentist did not choose the right appliance or properly adjust it for effective treatment. Their is both art and science to the field of Dental Sleep Medicine. Many doctors take a single course from a manufacturer of appliances and only have one tool in their belt. When I teach my courses I purposely limit class size to six dentists and their teams to insure that each dentist has a comprehensive understanding of sleep medicine and the role of the dentist. It is also important to understand the basic principles and how different anatomy may demand different types of appliances. I do have my favorits based of effectiveness.

I am frequently asked by dentists what is the best oral appliance. The answer is that it depends on many factors and different appliance are best for different patients.

Surgery is also an option for treating sleep apnea but is no longer considered a first line treatment because of high morbidity and poor results. I stronly suggest you avoid soft palate surgery ie UP3, LAUP, Somnoplasty, Pillars. Tongue reduction is a more useful surgery but can be brutal. If contemplating base of tongue surgery somnoplasty is a good choice but several procedures will probably be necessary. Nasal surgery can be helpful but is rarely a cure. It can make both oral appliance therapy and CPAP more effective and comfortable and can improve your quality of life if you live with chronic impaired breathing 24/7.

Bimaxillary advancement or madibular advancement or chin advancement can be very effective but a trial with an oral appliance is recommended prior to surgery to determine the amount of advancement that is necessary. You do not want to go thru traumatic surgery and still need CPAP afterwards.

If you are in the midwest, Illinois or Wisconsin feel free to see me in Chicago, Gurnee, Skokie, Vernon Hills or Schaumburg.
Good Luck Tom

Chronic Cough? Sleep apnea evaluation is probably indicated according to new article in Journal Cough.

A new article in the Journal Cough suggests that patients with chronic cough should be evaluated for obstructive sleep apnea (OSA). The article "Chronic cough and obstructive sleep apnea in a community-based pulmonary practice." details evaluation of 75 chronic cough patients. 38 of these patients were evaluated for OSA and 33 were positve for OSA. That translates into 44% of all patients had OSA. That also translates into over 86% of patients with a chronic cough were positive for sleep apnea. The authors also reported "93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough" which is an incredible relief. This is especially true since CPAP causes cough in some patients. The patients who did not get relief from CPAP should be evaluated on an oral appliance. Oral Appliances are better tolerated than CPAP by the majority of patients with obstructive sleep apnea.

The article Quantifying chronic cough: objective versus subjective measurements." from Respirology. 2010 Nov 5 discusses counting coughs and this approach could be used in patients to see if there is a circadian pattern to the coughs in apnea vs non-apnea patients. The authors stated "Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity" .

A major fault of the authors, Sundar KM, Daly SE, Pearce MJ, Alward WT was that they did not go back and evaluate the other 37 patients for sleep apnea. I assume that the other patients were not "typical" sleep apnea patients but many patients with sleep apnea do not fit the typical pattern of obese, thick neck and older male patient. If the 86% OSA figure was consistent throughout the Chronic cough population than perhaps chronic cough would be an absolute indication for sleep apnea testing.

Another interesting correlation would be to GERD (gastroesophageal reflux) and OSA which is a known risk factor for GERD. GERD accounted for 37% of cough population as a single etiology but GERD was also involved in multiple etiologies cough in 31 of the 75 patients. Multiple etiologies for the chronic cough included: GERD-upper airway cough syndrome (UACS), 31%, GERD-cough variant asthma (CVA), 5%, and GERD-UACS-CVA 3%

There is a commonality between cough, breathing, TMJ disorders and oral and pharyngeal reflexes. These reflexes that control breathing and pharyngeal structures are well described by A J Miller in "ORAL AND PHARYNGEAL REFLEXES IN THE MAMMALIAN NERVOUS SYSTEM: THEIR DIVERSE RANGE IN COMPLEXITY AND THE PIVOTAL ROLE OF THE TONGUE"

I have frequent references to his work in the www.ihateheadaches.org site and the www.ihatecpap.com site. These reflexes have direct effects on swallowing and breathing two essential functions of the jaws, tongue and oral cavity. Chronic misuse of these structures leads to repetitive strain injuries to the muscles and joints. These are frequently lumped into a junk diagnosis of TMJ, TMD, MPD, myofascial pain, Myofacial pain and are associated with sleep disorders, chronic pain, fibromyalgia and other central sensitization disorders involving the trigeminal nerve.

Cough. 2010 Apr 15;6(1):2.
Chronic cough and obstructive sleep apnea in a community-based pulmonary practice.
Sundar KM, Daly SE, Pearce MJ, Alward WT.

Intermountain Utah Valley Pulmonary Clinic, 1055N, 300W, Provo, UT 84604, USA. krishna.sundar@imail.org
Abstract
BACKGROUND: Recent reports suggest an association between unexplained chronic cough and obstructive sleep apnea (OSA). Current guidelines provide an empiric integrative approach to the management of chronic cough, particularly for etiologies of gastroesophageal reflux (GERD), upper airway cough syndrome (UACS) and cough variant asthma (CVA) but do not provide any recommendations regarding testing for OSA. This study was done to evaluate the prevalence of OSA in patients referred for chronic cough and examine the impact of treating OSA in resolution of chronic cough.

METHODS: A retrospective review of chronic cough patients seen over a four-year period in a community-based pulmonary practice was done. Patients with abnormal chest radiographs, abnormal pulmonary function tests, history of known parenchymal lung disease, and inadequate followup were excluded. Clinical data, treatments provided and degree of resolution of cough was evaluated based on chart review. Specifically, diagnostic testing for OSA and impact of management of OSA on chronic cough was assessed.

RESULTS: 75 patients with isolated chronic cough were identified. 44/75 had single etiologies for cough (GERD 37%, UACS 12%, CVA 8%). 31/75 had multiple etiologies for their chronic cough (GERD-UACS 31%, GERD-CVA 5%, UACS-CVA 3%, GERD-UACS-CVA 3%). 31% patients underwent further diagnostic testing to evaluate for UACS, GERD and CVA. Specific testing for OSA was carried out in 38/75 (51%) patients and 33/75 (44%) were found to have obstructive sleep apnea. 93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough.

CONCLUSIONS: OSA is a common finding in patients with chronic cough, even when another cause of cough has been identified. CPAP therapy in combination with other specific therapy for cough leads to a reduction in cough severity. Sleep apnea evaluation and therapy needs to considered early during the management of chronic cough and as a part of the diagnostic workup for chronic cough.

PMID: 20398333 [PubMed]PMCID: PMC2861010Free PMC Article

Respirology. 2010 Nov 5. doi: 10.1111/j.1440-1843.2010.01893.x. [Epub ahead of print]
Quantifying chronic cough: objective versus subjective measurements.
Faruqi S, Thompson R, Wright C, Sheedy W, Morice AH.

Division of Cardiovascular and Respiratory Studies, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, United Kingdom. HU16 5JQ.
Abstract
Background and objective: The assessment of chronic cough has been improved by the development of objective ambulatory cough monitoring systems and subjective quality of life questionnaires. Experimental induction of cough is a useful tool in the assessment of the cough reflex. We wanted to assess the reproducibility of and association between these measurements. Methods: This was a prospective observational study in patients with chronic cough of greater than six months duration. All patients had an initial 24 hour cough recording. They also completed a Leicester Cough Questionnaire, a Symptom Assessment Score, a Visual Analogue Score for cough and had a capsaicin cough challenge performed. They were reviewed at 8 weeks when all assessments were repeated. Results: The study included 25 patients (15 females) with a mean age of 54 years. The median cough count at the second visit (302) was significantly lower compared to the first visit (381, p<0.01). However the cough counts at both the visits correlated well (r=0.9. p<0.01).All the other forms of assessment were found to be highly reproducible at 8 weeks (r= 0.6-0.9, p<0.01). Cough counts correlated well with the other forms of assessment (r= 0.4-0.6, p<0.01). There was good correlation between each of the subjective forms of assessment (r= 0.6, p<0.01). Conclusions: The various forms of assessment of cough are reproducible. Cough counting correlates well with subjective assessment of cough and cough reflex sensitivity. It appears to lie between these latter two assessments of cough and may represent the best global objective synthesis of cough.

© 2010 The Authors. Respirology © 2010 Asian Pacific Society of Respirology.
PMID: 21054670 [PubMed - as supplied by publisher]