It was the middle of the night as I lay in bed, wide-awake. The problem – my husband had been snoring so loudly that my entire neighborhood was probably awake. This had become a nightly occurrence in my home until separate bedrooms became the only possible answer to afford a good night’s sleep for me. This situation persisted until a friend suggested that my husband probably suffered from sleep apnea. She explained that sleep apnea is a morbid disorder and that he should be tested in the hospital sleep lab where she worked. Morbid disorder was all that my husband needed to hear to get him on the phone to be scheduled. He was tested and diagnosed with severe sleep apnea. He now uses a CPAP (continuous positive airway device) and we both sleep soundly in the same bed, all night long. This story is not fiction; it is a true story about me, the author of this article.

In my role as a practice management consultant, I encourage my clients and their staff members to learn how to file medical claims. Dental procedures that fall under medical dysfunction, including oral appliances for sleep apnea, are among those that can be filed with medical third party carriers. My husband’s diagnosis of sleep apnea, and the facts about it that I have since learned, have been a driving force behind this aspect of my consulting.

Obstructive sleep apnea syndrome (OSA) is a disorder whereby there are episodes of breathing that nearly or completely stop for periods of time during sleep that dramatically raise blood pressure. In addition to sleep apnea, there is upper airway resistance syndrome that affects mostly women. Wellmark Blue Cross Blue Shield states that "Upper airway resistance syndrome is a variant of OSA that is characterized by a partial collapse of the airway resulting in increased resistance to airflow. The increased respiratory effort required results in multiple sleep fragmentations as measured by very short alpha EEG arousals." Both OSA and UARS fall under the heading of "sleep disordered breathing" (SDB). The morbid disorder, SDB, has been reported to affect 24% of adult males, 9% of adult females, and 10% of children. ¹ A recent article in Consumer Reports titled "Snoring: Deadly Din?" listed the morbid consequences of SDB as "a doubled risk of hypertension, a tripled risk of coronary heart disease, and a quadruple risk of stroke." ² In addition, there is the possibility of accidents due to sleepiness. The consequences in the home are obvious.

You may ask what dentistry can do to help these patients. My first answer is to review your examination methods. Look at your patients more closely. OSA patients typically present with short, thick necks and have rounded bellies or are obese. Upon examination, look for an elongated palate and uvula, or large tonsillar pillars with redundant lateral pharyngeal wall mucosa. Uvular edema is one of the most common physical findings in SDB. Craniofacial abnormalities that include micrognathia, retrognathia, or maxillary hypoplasia are also associated with OSA. In addition, a large tongue that limits the view of the uvula is another indicator. ³ Ask questions such as:

• Do you snore?
  
  
• Do your feel excessively tired during the day?
  
  
• Do you have high blood pressure?
  
  
• Do you wake up during the night?

If the patient presents with some or all of these symptoms and answers yes to any of these questions, you should recommend that the patient see his/her doctor for a referral to a sleep lab for a Polysomnography. This is a nighttime study that scores how many times per hour a patient stops breathing or almost stops breathing.4 If the patient balks at this, you can suggest a home sleep test such as the ApneaLink by ResMed (resmed.com) or the Compass by MedCare (medcard.com). These are not as comprehensive as the testing in a sleep lab, but it is better than no testing at all.

Once testing has been completed and a diagnosis of SDB has been made, one of the following treatments will most likely begin:

    Medical Treatments

         CPAP (continuous positive airway device – blows room air into the patient to keep the airway open)

         BiPAP (bi-level positive airway pressure – blows room air into the patient to keep the airway open)

         DPAP (demand positive airway pressure – blows room air into the patient to keep the airway open)

         Intra-oral appliances

1. mandibular advancing or repositioning device that positions the lower jaw forward, thus moving the tongue and soft palate away from the back wall of the throat.
   
   
2. tongue-retaining device that keeps the tongue in an anterior position

    Surgical treatments such as an Uvulopalatopharyngoplasty may also be suggested.

This is where dentistry can again play a role. Oral appliances may be indicated when:

• The patient is diagnosed with mild to moderate SDB
  
  
• The patient cannot tolerate CPAP, BiPAP or DPAP or does not adhere to the treatment
  
  
• Behavior modification such as diet or sleep repositioning has not been successful
  
  
• Surgery would not be appropriate
  
  
• The patient has an adequate protrusive range of motion of the mandible

You may ask when oral appliances would not be indicated. The following situations would dictate this:

• Patients with severe SDB
  
  
• Patient dentition that would not be able to support the appliance
  
  
• History of an unhealthy TMJ
  
  
• History of prior appliance therapy that was unsuccessful or not adhered to
  
  
• Patients allergic to the components of an appliance

The third area of help that dentistry can provide is the attempt to procure insurance benefits for patients who are treated with oral appliances for SDB. The process of medical coding for dental procedures is explained in my article "Crack the Code" that can be found in the March 2005 issue of Dental Practice Report. It is recommended that you contact the insurance carrier by phone to determine if an oral appliance is covered, to ask if a pre-authorization is needed, and to document the medical necessity. To file a claim, reference my article as to the procedures and use the following codes:

    ICD-9-CM (diagnostic codes) – choose the appropriate code for each claim

         780.51 Insomnia with sleep apnea

         780.53 Hypersomnia with sleep apnea

         780.57 Other and unspecified sleep apnea

    CPT (or HCPCS) (procedure codes) – choose one of the following

         S8260 Oral orthotic for treatment of sleep apnea, includes fitting, fabrication, and materials (this is a HCPCS code and most closely identifies the procedure to those carriers who accept HCPCS in addition to CPT)

         21089 Unlisted maxillofacial prosthetic procedure (CPT code)

         21110 Interdental fixation device (CPT code)

Please note that you should not file a medical claim for an oral appliance for snoring when there is no diagnosis of SDB.

These claims will need a narrative attachment. The coding manual "Cross-Walking, A Guide Through the Cross-Walk of Dental to Medical Coding", written by the author, explains the process of filing narratives and gives examples of narratives for SDB appliances and other dental procedures. You will need to attach a copy of the documentation showing the diagnosis made by the patient’s physician and include any sleep study reports. When filing, you may wish to include in your narrative a notation that the FDA has approved the oral appliance for the treatment of snoring, with or without sleep apnea. Make sure that the appliance you use has been approved before making that statement.

You also may need to appeal the insurance carrier’s decision if they deny benefits, or have the patient handle that. The manual also provides information on dealing with appeals and how to train patients to appeal for themselves.

I recommend that you require the patient to pay in full at the time of service. Medical insurance carriers are not always quick to respond to claims such as these. Kindly inform the patients that filing medical claims is a courtesy and that the insurance carrier may or may not pay and, if they do, it may take quite awhile. Tell them that you appreciate their understanding regarding your need to be reimbursed for services in a timely manner.

In conclusion, test results on oral appliances for SDB are few and limited. These appliances have been quite effective for snoring alone, but the jury is still out on the effectiveness for SDB. However, according to Blue Cross Blue Shield of Massachusetts in their article titled "Sleep Disorders Diagnosis and Treatment", "for OSA, the majority of patients studied show improvement".

The dental profession has a great opportunity to assess patients and recommend treatment, whether by referral or by treating with oral appliances, for those patients presenting with SDB symptoms. How many others get to look into someone’s mouth on a routine basis and look for signs of SDB? Remember, SDB can be morbid. Reggie White, a 42-year-old Hall of Fame football player, died from sleep apnea. We owe it to our patients to help them LIVE with this disorder.

1. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle aged adults. New England Journal of Medicine1993; 328(17):1230-1235
   
   
2. Snoring: Deadly Din. Consumer Reports. October 1999;64(10):38-46
   
   
3. Sleep Apnea and Upper Airway Resistance Syndrome. Wellmark Blue Cross Blue Shield. April 26, 2005:1
   
   
4. Sleep Disorders Diagnosis and Treatment. Blue Cross Blue Shield of Massachusetts. Policy: 293; Reviewed: March 2005:1-1