It seems like Medicare is always changing its rules, and these rules never seem to make things easier for us, they just make more hoops for us to jump through. And now this new change could keep many obstructive sleep apnea (OSA) patients who have difficulty with CPAP from getting oral appliance therapy. That is, if they don’t precisely follow the rules relating to turning in their CPAP machines on schedule.

Another Medicare Hoop to Jump Through?!

The New Rule

According to the new rule, OSA patients have to carefully observe the required return policy for their CPAP machines. If they do not return their CPAP machines within the initial 90 day trial period, then Medicare will not cover oral appliance treatment for a full five years. That’s because they consider it a duplicate treatment for the same condition, which causes them to deny coverage.

The only exception is when a significant change in medical condition keeps them from using their CPAP machine. This might include a serious sinus infection or facial surgery, which makes CPAP medically intolerable. Most of the normal factors that we find keep people from using their CPAP (such as claustrophobia, leaks, or strap problems) wouldn’t generally qualify because Medicare thinks that if people tolerated the CPAP through the 90-day trial, these can’t represent a valid reason to switch to an oral appliance.

How to Make Sure Your Patients Have Access to OAT

The good news is that if you are diligent, you can make sure that your OSA patients can still enjoy the benefits of oral appliance therapy if they don’t tolerate CPAP. Here’s how:

 

  • If you’ve prescribed CPAP: During the required return office visit with in the 90-day CPAP trial, talk to your Medicare patient about any problems with CPAP compliance. If they report any problems, encourage them to return their CPAP and get a receipt of return. Do this even if patients think they can live with the problems and still use their CPAP. Studies tell us that these complaints tend to worsen and drive down compliance rates with time. Instead, patients should seek oral appliance therapy as an alternative now, when it will be covered.
  • If you haven’t yet prescribed treatment: Consider prescribing oral appliance therapy for all Medicare patients with mild to moderate OSA. Because oral appliances have a much higher compliance rate, many studies show that they have equivalent outcomes for these patients. If your Medicare patient has severe OSA, they have to at least start with a CPAP trial. But make sure you talk to them about their difficulties with the treatment within the 90-day trial window. If they struggle, inform them of the option to receive appliance therapy, and make sure they understand that their window to switch treatments is limited.

 

If you communicate with patients, you can make sure they understand their options and get the most effective OSA treatment for them.

Have Questions about OSA and Medicare?

At the Advanced Dental Sleep Treatment Center, we have more than 30 years’ experience dealing with Medicare as well as private insurers’ changing policies. We understand the limits and strictures placed on these treatments and know how to navigate them to help patients get the most beneficial treatment.

If you have any questions about these policies, don’t hesitate to reach out and talk to Jody at (402) 493-4175 ext. 104

Respectfully,
Roger W. Roubal, DDS, DABCP, DABDSM, DABCDSM, DACSDD