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201907-119292

2019

United Healthcare Plan of New York

HMO

Respiratory System

Durable Medical Equipment (DME) (including Wearable Defibrilllators)

Medical necessity

Overturned

Case Summary

The patient who presents to the dental office for evaluation and treatment of his sleep apnea with an oral repositioning appliance.
It has been documented in the provided records that the patient does not have active periodontal disease and that he does not tolerate the continuous positive airway pressure (CPAP) device.The subject under review is the medical necessity of the planned treatment of sleep apnea appliance (EO486).The health plan's determination of medical necessity is overturned in whole. The patient is documented to currently suffer from mild to moderate sleep apnea, has attempted to use the continuous positive airway pressure (CPAP) and no longer tolerates the device, has a full dentition, does not have active periodontal disease, and is currently under the care of a dentist.Mandibular sleep appliances for the advancement of the mandible are a documented therapy for which there is greater compliance amongst patients who have previously used CPAP either with poor compliance or results. The majority of the literature supports the mandibular advancement device for patients with diagnosed sleep apnea and it is considered to be the standard of care for those who cannot or will not wear a CPAP. Hence, based on the documentation and the medical literature, the treatment of sleep apnea appliance (EO486) is medically necessary for this patient.

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