Oral Devices for Custom Fabricated Oral Appliances for Treatment of Obstructive Sleep Apnea Form

Harvard Pilgrim HealthCare
Medical Policy

Oral Devices for Custom Fabricated Oral Appliances for Treatment of Obstructive Sleep Apnea

Subject:

Oral Devices for Custom Fabricated Oral Appliances for Treatment of Obstructive Sleep Apnea

Background:

Obstructive sleep apnea (OSA), the most common form of sleep apnea, is the collapse of the upper airway leading to the reduction or cessation of airflow during sleep. These episodes may be associated with oxygen desaturation. There are three different forms of sleep apnea, obstructive, central, and mixed. The Apnea Hypopnea Index (AHI) represents the average number of apneas and hypopneas experienced each hour during sleep and is a diagnostic used to tool determine the presence and severity of obstructive sleep apnea.

Oral devices are used to treat obstructive sleep apnea (OSA) by restoring airway competence. The restoration of airway competence is intended to reduce morbidity and mortality by reversing hypoxia, hypercapnia, and acidosis as well as improving quality of life.

Authorization:

Prior authorization is required for oral devices for obstructive sleep apnea requested for members enrolled in commercial (HMO, POS, and PPO) products. This policy utilizes InterQual^® criteria, which Harvard Pilgrim has customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)
• Photographs — HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual^® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, Harvard Pilgrim draws upon the following InterQual^® criteria:

• Mandibular advancement oral appliance, Adjustable, Custom Fabricated Mandibular advancement oral appliance (Version 2023)

In addition, the member must be aware of the following:

• Positive airway pressure (PAP) is superior at improving the AHI and oxyhemoglobin saturation. Oral appliance therapy may not provide optimal improvement in oxygenation.
• Possible side effects with oral appliance treatment, including complications of TMJ

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers oral devices for the treatment of oral sleep apnea (OSA) as not medically necessary when the above criteria are not met.

Exclusions:

In addition, HPHC does not cover oral appliances when:

• The Member is less than 18 years of age
• The requested oral appliance is available over-the-counter or is not custom-made
• The Member has a diagnosis of central sleep apnea
• The oral appliance is being requested for snoring without documentation of OSA
• The oral appliance is being requested to treat central sleep apnea

HPHC Medical Policy

Oral Devices for Custom Fabricated Oral Appliances for Treatment of Obstructive Sleep Apnea

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Mandibular Anterior Repositioning Appliances/Devices

Mandibular Anterior Repositioning Devices should only be constructed by a dentist with experience in this type of appliance. Compliance and efficacy will be dependent upon the comfort and fit of this appliance.

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Facility PAP titration study and unattended auto-titration of PAP (APAP) do not qualify as a trial of PAP

• Convenience item (e.g., for travel)
• Nasal Dilators are not considered appliances for OSA
• Disturbed/interrupted sleep of spouse /partner