After requests from dental sleep medicine practitioners, the Centers for Medicare and Medicaid Services has changed its coverage determination to encompass traditional and digital impression options.
Not many people would argue that it is fun to lean back in a dental chair as you hear the words “open wide” before a large tray of blue goop is slid into your mouth. Then, for five minutes, you must hold still, trying not to gag, as the substance solidifies, but not without some of it, potentially, running down the back of your throat. This is often what it takes to make a model of the teeth to construct an oral appliance, the device that shifts the jaw forward to keep the airways open, making it easier for people with obstructive sleep apnea (OSA) to breathe during the night.
The patient experience of traditional impressions is one reason why dentists who treat OSA are turning to digital scans, a newer technology that creates an image of mouth anatomy, with no goop involved. Many third party payors have OK’d these digital scans, which research has shown are just as accurate as manual impressions, but Medicare lagged behind—up until now.
The Centers for Medicare and Medicaid Services (CMS) recently OK’d digital impressions for Medicare beneficiaries who need oral appliances for sleep apnea. The change to the coding guidelines comes after a push made by dental sleep medicine advocates who pointed out the need to shift the local coverage determination (LCD) to reflect the current state of the industry.
“Digital scans and digital impressions are the future that is here now, and they provide a really terrific benefit to the patients because these scans can be taken without gagging the patients as traditional impression materials often do,” says Vicki E. Cohn, DDS, DABDSM, clinical director at Sleep Apnea Dentists of New England.
Cohn often comes across patients who have restricted airways, and often times, a higher gag reflex. These patients can suffer from anxiety associated with sitting in the dentist’s office chair and manual impressions can exasperate these problems.
“Many of the practitioners in the dental sleep community are using digital impression scanning techniques routinely for all patients since they believe this is a superior technique and, for them, the new standard of care. We do not want to have to treat our Medicare patients at what we personally believe to be a lower standard of care,” Cohn wrote in a letter to medical directors at CMS to ask for the change.
Fear and anxiety around conventional impression techniques can delay therapy. “For some patients it is a roadblock for care,” Cohn says.
In her letter, Cohn provided educational material to support the use of digital scans and to explain the difference between digital scans and manual impressions.
Digital impressions are taken with a small camera that looks like a wand, which is moved throughout the patient’s mouth to capture thousands of images. Those images are then digitally stitched together. The digital file is sent to a lab nearly instantaneously, bypassing the days that it would take for a manual impression to arrive in the mail. Traditional impressions can also get lost or damaged in the mail. Overall, digital scans lead to faster treatment for patients, according to the letter Cohn sent to the CMS directors.
“You’re skipping three days of mail time, so if you have a patient and you definitely want to get this treated, you want to get this back as soon as possible,” explains Jan Palmer, FAADOM, a consultant and administrator for Sleep Apnea Dentists of New England who holds positions with two Medicare durable medical equipment provider education and outreach groups.
The cost of one of these digital scanners is steep and can run over $20,000, but the return on investment comes from improved accuracy over time, David E. Federici, DMD, of Federici Dental in Manahawkin, NJ, told Sleep Review in a previous article.
“The true savings is time and accuracy—as remakes and time inserting have dropped to barely any adjustments needing to be addressed. The time factor is both in scanning and no retakes of impressions as well as getting the cases back in half the time, which also means less temporary crown recementations and happier gum tissues with less time wearing a temporary,” he says. “And patients love the new technology and not having the goop in their mouths and retakes and gagging, etc.”
Overall patient comfort is a huge factor, Cohn adds. There is no excess material to drip down patients’ throats. Patients don’t have to open their mouths uncomfortably wide. If the patient needs to take a break for any reason, the digital impression procedure may be started and stopped without altering its accuracy, Cohn’s letter continues.
Additionally, unlike a traditional impression, a digital scan can be securely stored on a computer and a new oral appliance can be made from the scan again later without loss of accuracy, says Cohn.
“It’s up and coming. It’s just so much better, and it is a lot easier on the patients,” says Palmer, who also advocated for coverage of digital scans for Medicare beneficiaries.
CMS recently released information on how to request new LCDs or revisions to existing determinations. To request new LCDs, send the request to your Medicare Administrative Contractor (MAC) in writing (email, fax, or letter); clearly identify the statutorily-defined Medicare benefit category which you believe the item or service falls under and provide a rationale justifying the assignment; identify the language you want in an LCD; include a justification supported by peer-reviewed evidence (with full copies of evidence); include the relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service; and explain the design, purpose, and/or method of using the item or service for which the request is made.
Lisa Spear is associate editor of Sleep Review.
Image: A 3Shape intraoral scanner is one option for creating digital impressions for oral appliances for sleep apnea.