Documentation Checklist for Oral Appliance Therapy of OSA Patients (for Medical Billing Service)

This checklist will serve as a guide of the criteria required for most medical insurance to approve coverage for OSA therapy.

Documentation Checklist for Custom-Made Oral Appliances for OSA

(Commercial/private insurance)

☐ Prescription/Written Order from physician (MD, DO, NP, PA or CNS) for oral appliance.

☐ Office visit notes from physician.

☐ SOAP note/narrative report from DentalWriter (from sleep history/exam/workup visit).

Your SOAP note should be documenting the patient's absence of significant periodontal disease and absence of TMJ dysfunction, and Epworth score of 11 or higher.

☐ Proof of delivery form signed by patient

☐ Lab slip and Invoice from Lab for oral appliance

☐ Copy of sleep study report with AHI 5+ (dated within 1 year prior to delivery date of appliance)

For mild OSA (AHI 5-15) – at least one of the following in medical history:

☐ Epworth sleepiness scale score 11+

☐ Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia

☐ Hypertension, ischemic heart disease, or history of stroke

For severe OSA (AHI 30+) – at least one and sometimes both:

☐ CPAP affidavit of intolerance/noncompliance

☐ Notes from physician that PAP therapy is contraindicated

Important notes:

The replacement period for E0486 is typically 5 years, and occasionally 3 years.
Non-warranty repairs to custom-made oral appliance are typically covered.
Some private medical insurers require that only appliances that have received written verification from PDAC may be eligible for coverage. See the current list of PDAC approved appliances approved for coding under E0486 here.