Sleep claim documentation checklist

This article will go over the required documentation for custom-made oral appliances for OSA (commercial/private insurance)

• Prescription/Detailed Written Order from a physician (MD, NP, PA) for E0486

• Evaluation/Office Visit Notes from the prescribing physician

• Copy of Sleep Study Report with an AHI of 5 or greater (dated within one year prior to the appliance delivery date)

• SOAP Note/Narrative Report from DentalWriter (detailing sleep history, examination, and workup)
  Note: Be sure to include periodontal and TMJ status in the exam notes. Insurance likes to see both of these on the SOAP note.

• If AHI is mild (5-15), at least one of the following should be documented in the medical history:

  • Epworth scale score of 11 or higher
  • Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia
  • Hypertension, ischemic heart disease, or a history of stroke

• If AHI is severe (30+), one of the following must be documented:

  • CPAP affidavit of intolerance or noncompliance (there is a CPAP intolerance affidavit template located under quick letters in DentalWriter)
  • Physician’s notes indicating that PAP therapy is not effective

• Proof of Delivery Form signed by the patient (there is a proof of deliver template located under quick letters in DentalWriter)

• Lab Slip for the oral appliance

• Invoice from the Lab for the oral appliance

Important Notes:

• The standard replacement period for E0486 is typically 5 years, but in some cases may be 3 years.
• Non-warranty repairs to custom-made oral appliances are generally covered.
• Some private insurers require appliances to have written verification from PDAC to be eligible for coverage. To view the current list of PDAC-approved appliances for E0486, please visit:
  https://www4.palmettogba.com/pdac_dmecs/searchProductClassificationResults.do?codeDecision=E0486