Consensus on Why, When and How Often we Need to Replace OSA Appliances
(Bradley Eli, Barry Glassman, Ivonne Hernandez, John Viviano, Abe Bushansky, Todd Morgan, Rick Mondick, Tim Mickiewicz, Steve Carstensen, Erin Elliott, Steve Lamberg, Promila Mehan, John Monacell, Bernard Robichaud)
The LinkedIn Discussion Group, “SleepDisordersDentistry”has just completed an open discussion on Why, When and How Often we Need to Replace OSA Appliances. Here is a consensus for all to ponder.
What was asked,
“OSA appliances have varying lifespans, in part due to the appliance itself, and in part due to the environment the appliance finds itself in. Let’s share our anecdotal experience regarding why, when and how often we need to replace OSA appliances, and also discuss any guidance the literature provides us regarding this issue…”
What was said,
The general consensus was that insurance provides for replacement of an oral appliance between 3 and 5 years. However, a number of clinicians indicated that for some patients, an appliance might last beyond 5 years, and as long as 10 years for appliances made with more durable materials such as nylon. The determining factors regarding longevity being the material used to manufacture the appliance (laminated appliances don’t last as long) and the level of parafunction.
The need for replacement is obvious when the appliance becomes uncomfortable, there is loss of retention, or depletion of further adjustment capability, cannot be cleaned properly due to material deterioration or it breaks. However, the issue of continued effectiveness can be less obvious. For example, is it due to the appliance not being retentive or changes in the patient’s physiology, which may not improve even with appliance replacement.
Regular “patient specific” follow-up was discussed, stressing the importance of follow-up to maintain and ensure both compliance and efficacy. Follow-up would also allow the dentist to monitor some critical indicators such as weight gain and onset of diabetes or hypertension. It was suggested that since CPAP is evaluated yearly for continued efficacy, this should be the same time frame for oral appliances. In fact, the AADSM recommends a patient be seen for follow-up 6 months after reaching an endpoint calibration and then yearly thereafter. It was also suggested that there are way too many variables to list regarding “when” one replaces an appliance and that the yearly recall should review not only efficacy, but also the need for continued wear. For instance, in cases of dramatic weight loss a patient may no longer require the aid of an oral appliance. The method of establishing continued efficacy was also discussed, some advocating purely subjective evaluation and referring back to the physician for objective evaluation and others advocating objective testing with HST.
Since insurance re-imbursement seems to cover replacement appliances at year 3 in many cases, it was discussed that this allows an opportunity for the patient to obtain a back-up appliance. It seems that this 3-year rule is held strictly, with the exception of the appliance being lost/damaged in a natural disaster, (flood, hurricane or tornado, etc.). So, it is important that a dentist selectively match an appliance with the environment it will be used in, such as in heavy bruxers, if their appliance is damaged prematurely due to heavy parafunction because the choice of appliance was not suitable for a bruxing environment, the patient will need to pay for a new oral appliance out of their own pocket. Apparently, Medicare will replace for any "Act of God" incident that renders an appliance unusable, even “act of dog", but it was not advocated that patients feed their old appliance to their pet dog ;). However, it was suggested to call the insurance company on each case and get the particular replacement policy. At this time, the major insurance companies in the US: United Healthcare, Cigna, Blue Cross and Blue Shield have initiated a 3-year replacement policy. CMS Medicare has initiated a 5-year policy, with “Act of God” or documented theft (police report) being the only exceptions. It was also reported that United Healthcare denies replacement of an oral appliance for the excuse, "my dog ate it”. Finally, regarding “act of dog”, it was pointed out that in some cases the patient’s home insurance policy may cover this loss.
Some clinicians discussed a reduced fee for replacement appliances and others discussed that in many cases, a replacement appliance did not result in “less work” as they had once thought, so they fee the full amount. In addition, since insurance is looking to set the fee for oral appliances based on the lowest fee charged, it may be sending the insurance companies the wrong message by submitting a reduced fee. It was also pointed out that you cannot legally charge the insurance company one fee and patients without insurance a different fee.
Regarding reimbursement levels, Abe Bushansky pointed out that,
“the usual and customary reimbursement rate for an oral appliance is independent of what an individual Dentist charges. The reimbursement rate is based upon the Plan Type, The Administrator Agreement with the insurance company for DME supplies (i.e pays 150% of Medicare), Zip Code where the services has been rendered and in certain situation the diagnostic code utilized. The Dental Office should have one set price for the oral appliance that is consistent for all submitted claims to the different insurance companies. The price that one charges a cash patient, however, is not registered and there is no mechanism for the Government to track these claims.”
In Summary,
It is important to frame things properly for our patients from the very first visit. Steve Carstensen suggested the following,
“If we help them understand that it is a lifetime challenge to keep their airway open every night, and no one can predict what's going to happen in the short term, much less after using the device every night for hours each night. We are providing a plastic (or nylon) device for this heavy use (what else in their life do they use that much?) so we are best to build expectations for ongoing assessment of how well it's working, and general ‘scuzziness’. People have varying degrees of tolerance of diminished performance and increased 'scuzziness', so we must keep them coming in to stay connected with their symptoms and wishes. Testing gives us tools for conversation.”
Steve Lamberg provided the following insights,
“When and if the mean disease alleviation can be enhanced....it's time to refresh their appliance. When someone asks how long will it last I hear something like ‘when will I have to spend more money on this’? I usually answer with.... ‘Mrs. Jones, how long do your eye glasses last? They can break by misuse or accident or your prescription can change.’ They are usually pleased to learn that we cover them for a minimum of 3 years and that their insurance company will cover the new one....at "X" months out.”
I would like to express a heartfelt thanks to all that participated in this discussion. As always, these consensus articles should be considered working documents, meant to guide those clinicians new to this field and also present some valuable insights to those of us that have been at it a while. I look forward to future discussions on our SleepDisordersDentistry LinkedIn group!
