Oral Appliance denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oral appliance (E0486) provided. Findings: The physician reviewer found that given the body of evidence to support the use of oral appliance therapy, the device at issue was effective in the treatment of this patient’s OSA. While the guidelines recommend CPAP as the first line therapy for patients diagnosed with OSA, they acknowledge that not all patients are tolerant of CPAP. In that setting, it is generally a standard practice to use alternative therapies to CPAP for patients with OSA who do not tolerate or respond to CPAP.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an oral device and associated services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s sleep apnea. Findings: In this case, the patient’s clinical presentation indicates a diagnosis of OSA and he is reported to be CPAP intolerant. The medical literature indicates that oral appliance therapy is an acceptable second line therapy option for CPAP intolerant patients with OSA (Epstein et al). Current practice guidelines from the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine support the use of oral appliance therapy in patients with mild or moderate OSA who are intolerant of or decline CPAP. The patient has been referred to a dental provider for an oral appliance.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee is requesting authorization and coverage for a durable dental mouth guard. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. The current literature recommends that a dental provider evaluate patients for adequate periodontal health and an absence of temporomandibular joint problems prior to use of an oral appliance. This is due to the potential side effects of oral appliance therapy, which include temporomandibular joint problems and tooth mobility. The medical records do not document that such an evaluation took place. Thus, the provision of an oral appliance would not be consistent with the generally accepted standards of care in this clinical setting. There is a lack of support for the requested device in this patient’s case.

Nature of Statutory Criteria/Case Summary: An enrollee has requested an evaluation for an oral appliance and an oral appliance for treatment of his obstructive sleep apnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services and equipment. In this patient’s case, he does not have clinically significant obstructive sleep apnea that requires treatment. If there is concern regarding positional changes of supine sleep, using a vest or shirt with a tennis ball sewed into the garment would prevent supine sleep. There is no indication for the requested oral device in this clinical setting. All told, the requested evaluation for an oral appliance and an oral appliance are not medically indicated for the treatment of this patient.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Oral Appliance, then check the rights and deadlines that apply to your plan.