Older adults seeking to use their Medicare benefits may face additional challenges in treating obstructive sleep apnea with oral appliances. Here’s what experts recommend.

By Alexandra Frost

After making it through an initial primary care physician visit, a sleep study, and a referral to a dental sleep medicine practitioner, obstructive sleep apnea (OSA) patients prescribed oral appliance therapy still have a learning curve ahead—figuring out how to use, wear, and adjust their new device. This can seem daunting to some Medicare beneficiaries, especially if they find it physically challenging to adjust their appliances, coordinate and remember follow-up appointments, and more.

Fortunately, dental sleep medicine practitioners can help senior adults who want to use their Medicare benefits overcome common therapy challenges, allowing them the possibility of finding more success with oral appliance therapy (OAT) than with CPAP or other options. There’s also a shorter wait time compared to CPAP to begin treatment due to supply chain shortages; the American Academy of Dental Sleep Medicine (AADSM) reports three weeks as the average wait for an oral appliance versus three-plus months for CPAP.1 

Researchers have determined some specific findings about OSA patients who are Medicare beneficiaries. In a 2020 study published in the Journal of Clinical Sleep Medicine, these adults were more frequently diagnosed with two or more sleep disorders when they were seen by board-certified sleep specialists relative to nonspecialists, which its authors say demonstrates the value of board certification in sleep medicine in caring for complex sleep patients.2 When it comes to treatment, another study has shown that in a selected Medicare population, CPAP treatment among older Americans varies greatly, especially by region, potentially making OAT a helpful alternative for them.3 What’s more, research has found that in a sample of over 10,000 Medicare beneficiaries with OSA, when the condition went untreated, patients utilized healthcare services substantially more,4 showing how essential it can be to treat OSA proactively.  

Oral Appliance Selection

One of the most challenging scenarios for Medicare beneficiaries is oral appliance selection, says AADSM president-elect Kevin Postol, DDS, DABDSM. Medicare limits their choice to Pricing Data Analysis and Coding (PDAC)-verified oral appliances, all of which must meet specific requirements. Criteria for HCPCS code E0486 (custom fabricated mandibular advancement devices) include having a fixed mechanical hinge at the sides, front, or palate. According to the Centers for Medicare and Medicaid Services, “Interlocking flanges, tongue and groove mechanisms, hook and loop or hook and eye clasps, elastic straps or bands, mono-block articulation, traction-based articulation, compression-based articulation, etc (not all-inclusive) do not meet this requirement.”5 Postol says, “This can reduce the ability for a patient to select their appliance of choice or a new type of appliance.”

“If I believe a non-PDAC-approved device may be best for the patient, I will have a discussion with them,” Postol says. “If a Medicare patient decides to move forward with an appliance that is not PDAC-approved, the patient must sign a private contract acknowledging they cannot use their Medicare benefits.”

Mark Murphy, DDS, lead faculty of clinical education for ProSomnus Sleep Technologies and owner of dental sleep practice Funktional Sleep in Rochester Hills, Mich, thinks Medicare’s oral appliance criteria are outdated. “Traditional PDAC-approved custom devices have a number of issues that compromise treatment for Medicare patients,” Murphy says, such as having to tinker with a Herbst arm to advance a tiny pinhole or wrench hard-to-adjust straps, as well as being difficult to clean. “These outdated materials and designs are one of the reasons physicians have not been advocates of OAT.”

As someone of Medicare age himself, Murphy, 66, feels passionate about this issue. He typically offers Medicare beneficiaries a choice: “either the best-in-class precision Herbst-style medical-grade material device or a two-device solution.” Murphy says, “One is a PDAC-approved appliance, and then have them sign an ABN [Advanced Beneficiary Notice of Non-Coverage] and offer a second or backup device for a modest fee. This fulfills the mandate and allows the patient to still get the best treatment for their disease without undue cost. The latest generation of precision oral appliances, now made from medical-grade materials, are smaller, require less dose, and are easier for this cohort of patients to adjust and keep clean.”

David Schwartz, DDS, DABDSM, and past president for the AADSM, says that if a patient cannot tolerate a PDAC-approved device due to discomfort, they may select to have another non-PDAC device, particularly one that is easy to use. “This device cannot be submitted as a separate charge to Medicare. Another challenge with PDAC-approved appliances is that many Medicare patients suffer from strokes, vision issues, and other debilitating health issues, so they need devices that are easy to insert, remove, and adjust,” he says.

Dental sleep medicine experts share other top considerations and recommendations for improving experiences for Medicare patients using OAT.

Overcoming OAT Barriers for Medicare Beneficiaries

Medicare beneficiaries sometimes encounter specific barriers in using oral appliance therapy for sleep apnea. Here is how to surmount several common obstacles.

Missing or Damaged Teeth

The National Institute of Dental and Craniofacial Research reports that just over 17% of seniors 65 years and older have no remaining teeth, and on average, seniors in this age group have an average of 20.7 remaining teeth. This can create an obstacle to getting started with OAT.6 

“It is a requirement that all patients have a dental fitness form completed by their dentist prior to receiving oral appliance therapy. The main points that we check for are that they have had a cleaning in the last six months, they have no pending dental work, with no periodontal disease,” says Jade Ramsey, chief operating officer of Ramsey Dental in Raleigh and Charlotte, NC. “All patients must also have at least eight permanent teeth on both the upper and lower arch to ensure proper retention of the device. With Medicare patients, this can be a hurdle as there is a higher chance that the patient may wear a partial or denture.”

Schwartz gives a recent example. “I had a female patient with extensive dental issues that compromised her oral health. She was a severe diabetic and needed to lose weight. Since she is on a fixed income and was concerned about the cost for treatment, I referred her to the dental school near her home, and she completed the necessary treatment,” he says. “She not only completed her dental care but brought her blood sugar levels into the normal range, lost weight, and is now able to proceed with her treatment.”

So, other oral health improvements might be necessary before OAT is an option.

Difficulty Titrating Devices

Titrating oral appliances can be a barrier for some patients, says Dennis Stiles, DDS, a professor at the University of Maryland Dental School where he teaches sleep medicine.

“Manual dexterity and being able to see the little holes that you have to put the tool in to turn it—those are challenges,” he says. One way he tries to help educate patients is by taking a video of his directions that they can reference later when they adjust the device. 

Some providers allow patients to titrate their own devices, while others prefer to do it with them in the office. Ken Mogell, DMD, DABSDM, a dental sleep medicine practitioner in Florida, where around 65% of his OSA patients are Medicare beneficiaries, says, “For the most part, we don’t have a problem, but sometimes patients will come in and have advanced one side 15 turns and one side five, and they’re wondering why they have muscle soreness,” he says. “But we try to control the environment as much as possible.”

Educating a family member on how to titrate can help the patient remember to do it, and how to do it, as well, adds Postol.

Remembering to Follow Up with the Care Team

To ensure the most effective products for OSA, follow-up care—both with the durable medical equipment provider and the sleep medicine doctor involved—is essential. 

According to Ramsey, one difference with Medicare reimbursement is that it requires patients to have had a baseline sleep study in the last 12 months, versus the last 24 months, as with some other payors. “This would be the first and most important document for reimbursement,” she says.  

Frequent check-ins help keep patients and clinicians talking about how well the product is working and give them a chance to bring up other health considerations. “With our patients with Medicare, or some of our elderly patients, we will see them every two to four weeks to evaluate them,” Mogell says.

Navigating Reimbursement Criteria

Reimbursement processes are important with Medicare. Postol says the following tips help:

  • Always use appropriate modifiers to indicate all the required documentation is complete.
  • Verify that all the documentation listed in the local coverage determination for oral appliances is included.
  • Verify, when checking reimbursement criteria, that the patient is not impacted by Medicare’s “same or similar” policy, in which they may not reimburse for specific services when another service was provided within a specified time period for that service.
  • Prioritize annual visits with the sleep physician and treating qualified dentist.

For some Medicare beneficiaries, oral appliance therapy has been a lifesaver. Jade Ramsey, who works with dental sleep medicine practitioner Darren Ramsey, DDS, explains that Darren Ramsey’s mother, a Medicare beneficiary, significantly improved her quality of life after switching from CPAP to oral appliance therapy. “It changed her whole life,” she says. “She has been traveling more, getting more restful sleep, has come off many of her medications, and even lost weight.” 

References

  1. Sleep soundly with an oral appliance: An effective alternative to CPAP. American Academy of Dental Sleep Medicine website. Available at mms.aadsm.org/members/directory/search_bootstrap.php?org_id=ADSM&gclid=CjwKCAjw6IiiBhAOEiwALNqncRS-w4prJzxX6m0kZbSo3QM59uwA1p1-V1LwxjcF-0nzKi68psBJphoCh8sQAvD_BwE.
  2. Wickwire EM, Jobe SL, Parthasarathy S, et al. Which older adults receive sleep medicine specialty care? Predictors of being seen by a board-certified sleep medicine provider. J Clin Sleep Med. 2020 Nov 15;16(11):1909-15.
  3. Dunietz GL, Yu Y, Levine RS, et al. Obstructive sleep apnea in older adults: geographic disparities in PAP treatment and adherence. J Clin Sleep Med. 2021 Mar 1;17(3):421-27.
  4. Wickwire EM, Tom SE, Vadlamani A, et al. Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients. J Clin Sleep Med. 2020 Jan 15;16(1):81-9.
  5. Oral appliances for obstructive sleep apnea – policy article. US Centers for Medicare & Medicaid Services website. Available at www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52512.
  6. Tooth loss in seniors. National Institute of Dental and Craniofacial Research website. Available at www.nidcr.nih.gov/research/data-statistics/tooth-loss/seniors. 

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