Tap III and Insurance Question

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Tap III and Insurance Question

Postby 442olds » Thu Jan 29, 2009 12:40 am

I had a Tap III appliance made for my sleep apnea last October.I have had decent success with the appliance,but my Blue Cross medical insurance has denied payment after numerous appeals.They say that this device is not FDA approved and has no CPT code whatever that means.It is beyond me how they can pay for a C PAP machine which I found to be totally useless,yet the TAP III is MUCH cheaper and they have rejected my claim.Any advice for me?They say that they need a CPT code and maybe they could then process the claim.Thanks!
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Postby ApneaKiwi » Thu Jan 29, 2009 1:57 am

the person who prescribed it (ie dentist or doctor?) is probably the only person who can help with that. i know it's expensive and it's a real shame it's not covered, but look at it this way - you have a treatment that works - and that is a thing of immense value. often there are costs in healthcare that aren't covered and we have to use money that we would rather spend on a vacation or a sofa. some of us don't even have that.

insurance companies, in fact any funding organisations, have to rely on some form of independent verification that a treatment works and is safe. many treatments that do work are not necessarily approved yet, or ever. but by and large, most things are, for most people. if you need a heart bypass or antidepressants, it's covered. for most people with OSA, CPAP works and is safe. that is the basis on which the FDA and the insurers have to make their decisions. don't forget, CPAP users also have alot of hidden costs for some consumables, some replacement parts, out of pocket costs and even the electricity that no one reimburses us for.
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Might help check the link out

Postby papahemi » Thu Jan 29, 2009 10:25 am

I don't know if this information will help you but it may be a start. Check out the link for the Somnodent MAS. It is an FDA approved device. Hope it helps. My HMO insurance would not accept a dental device claim so I am appealing calling it a medical mandibular repositioning appliance. Here is the link: http://www.somnomed.com/dentists-resource.html
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TAP & insurance

Postby DSCorbin » Mon Apr 06, 2009 11:29 pm

My sleep specialist sent a letter of "Medical Necessity" and described the device as a prosthetic device which was subsequently accepted by my HMO. I'm trying to find the letter he sent & will post it verbatum when I do. I was unable to tolerate the CPAP machine but have had success with the TAP II and am waiting for TAP III to arrive. I'm a grinder and have cracked my original, though it still works. Papahemi has the right idea.
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Oral appliances & Insurance

Postby DSCorbin » Fri Apr 24, 2009 4:20 pm

I found the "Certificate Of Medical Necessity" sent by my Sleep M.D. to the insurance company. Directly quoting...
"Regarding Thornton Airway Positioner; This individual has significant obstructive sleep apnea/hypopnea syndrome. I have discussed various treatment options with this individual and have recommended The T.A.P. This device is a custom-fit oral splint designed to maintain the mandible in a more anterior position, thereby keeping the airway open in sleep. In a peer reviewed journal "Chest 119:1511-1158, (1999,) Pancer et al have demonstrated a mean reduction in the respiratory disturbance index from 44 events/hour to 12 events/hour in a group of 75 patients treated with the device. The respiratoty disturbance index dropped to less than 10 events/hour in 53% of the patients. The RDI dropped by greater than 50% in 81% of subjects. I have suggested that the above individual be treated with this device. Such treatment is medically necessary in order to eliminate the hypersomnolence and cardivascular risks accociated with this disorder."
Hope this helps
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Postby kanelakos » Thu Jul 30, 2009 7:01 am

I fought with my insurance company for around 4 months. BCBS said it fell under dental and dental said it was a medical device. I got a prescription from a Neurologist/sleep doctor. BCBS denied my request for pre-authorization but after an appeal, they approved. Keep fighting and let them know you will not go away. I one point I said OK, if you wont approve this $1400 device, I will opt for the surgery that will cost you... hmmm... maybe 10 grand!!!?? It got their attention.
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Insurance Billing Information for Oral Appliance Therapy

Postby jjames7118 » Fri Feb 19, 2010 5:29 pm

Commercial Insurance Billing Information for Oral Appliance

CPT Codes: (Common Procedural Terminology)
New patient exam and evaluation (CPT code 99203) or existing patient exam and evaluation (CPT code 99214) may be billed separately from the appliance. It is important to document the extent of the visit in the patient's chart. CPT codes 99203 and 99214 are for relatively complex medical problems which affect multiple organ systems. Sleep apnea falls into this category if there are co-morbidities such as obesity, GERD, hypertension or diabetes.

The billing code for the Oral Appliance is from the Healthcare Common Procedure Coding System (HCPCS),
HCPCS code E0486 defined as : Oral Device to Reduce Airway Collapsibility

The Diagnostic Code is from the ICD9 (International classification of Diseases 9th Edition) and is 327.2 for Obstructive Sleep Apnea

Most commercial insurance companies are currently requiring that the patient has either failed CPAP therapy or is unable to tolerate an attempt. Therefore it is necessary to obtain a letter of referral documenting the patient’s inability to use CPAP and an Rx for the TAP from the patient’s treating physician. This can be their primary care physician, a treating specialist in any discipline and does not need to be the sleep specialist. Having said that, the patient must have had a sleep test that has been read by a Board Certified Sleep Specialist in order to validate a diagnosis of obstructive sleep apnea. Most patients are referred back to their treating physician once the sleep study has been done or their treating physician can request a copy of the sleep study and diagnosis.

There are no predictable standards of payments for oral appliance therapy at this time as the insurance industry catches up to changes in the treatment paradigms for obstructive sleep apnea.

Obstructive Sleep Apnea is a MEDICAL DIAGNOSIS that can in many cases be treated with an oral appliance that MUST BE FITTED BY A DENTIST. Since it is a medical condition it is payable under the medical insurance policy not the dental. Only dentist are qualified to fit and manage an appliance that involves the tooth structure. Oral appliances leverage one's dental structure in order to splint the airway open. The principle behind this is the reason the first step in administering CPR is to pull the patient's jaw forward to open the airway. One of the most important things the health care community can do for those of us who suffer from this breathing disorder is for physicians and dentists to work collaboratively not competitively.

I hope this is helpful.
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Re: Tap III and Insurance Question

Postby bwilson4web » Fri Jun 08, 2012 3:14 pm

Hi,

I have split coverage:

BCBS - will cover the medical device (THANKS! The code for the device works!)
Aetna - not sure ... they wanted a 4 digit code to cover the 'fitting'/'exam'?

I gave the Aetna support person the code "99214" and she said 'that is a medical code, we need the 4-digit dental code.'

Any idea what that code might be?

Thanks,
Bob Wilson
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Re: Tap III and Insurance Question

Postby a.b.luisi,d.m.d. » Sat Jun 09, 2012 4:20 pm

bwilson4web wrote:Hi,

I have split coverage:

BCBS - will cover the medical device (THANKS! The code for the device works!)
Aetna - not sure ... they wanted a 4 digit code to cover the 'fitting'/'exam'?

I gave the Aetna support person the code "99214" and she said 'that is a medical code, we need the 4-digit dental code.'

Any idea what that code might be?

Thanks,
Bob Wilson

I am a dentist working in dental sleep medicine. That is certainly a strange request from AETNA. The dental code would be D0150-- comprehensive oral evaluation. Be sure to use the D first or they will reject that too.
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Re: Tap III and Insurance Question

Postby rjoker53 » Sun Jun 10, 2012 8:46 pm

This is a very important topic. I can safely say we'll continue to see TAP III & other OA insurance threads over the coming years as more sleep apnea sufferers discover the OA option & decide to pursue it. I greatly admire the persistence of any of you that continue to fight for it, esp. in dealing with Blue Cross Blue Shield (BCBS). Yes, I cannot emphasize the importance of using the right codes and other procedures when filing the claim. My experience is that the dental offices either don't have the training/knowledge of the codes and other ways to properly file the claims to have the best shot at coverage or helping is not a priority for them. I realize this is not the case with every dental office and I greatly commend those who go the extra mile to try and help those sleep apnea sufferers who get dental devices from them file successful claims.

I probably gave up too easily after receiving my TAP 3 in Ocotober of 2011. Fortunately, relatives helped me with loans that I have since repaid so it was all funded out of pocket.

The organization for which I work will switch from BCBS to United effective Sept. 1 of this year. From reading previous threads on this topic, United seems to be more willing to cover oral applicances for OSA than BCBS, but I am not certain. Has anyone out there made a successful claim with United for TAP or Somnodent with United? If so, please share your experiences since I know of at least one person who really wants an oral device and would likely get it if United covers it.

Unfortunately, it will likely take something like a very influential insurance executive or the relative of one getting OSA, not being able to use CPAP, wanting an oral device and experiencing many of the same things from greedy insurance companies that many of us have experienced before it will get much easier. Realistically, I doubt that will happen anytime soon.
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Re: Tap III and Insurance Question

Postby a.b.luisi,d.m.d. » Wed Jun 13, 2012 8:15 pm

rjoker53 wrote:This is a very important topic. I can safely say we'll continue to see TAP III & other OA insurance threads over the coming years as more sleep apnea sufferers discover the OA option & decide to pursue it. I greatly admire the persistence of any of you that continue to fight for it, esp. in dealing with Blue Cross Blue Shield (BCBS). Yes, I cannot emphasize the importance of using the right codes and other procedures when filing the claim. My experience is that the dental offices either don't have the training/knowledge of the codes and other ways to properly file the claims to have the best shot at coverage or helping is not a priority for them. I realize this is not the case with every dental office and I greatly commend those who go the extra mile to try and help those sleep apnea sufferers who get dental devices from them file successful claims.

I probably gave up too easily after receiving my TAP 3 in Ocotober of 2011. Fortunately, relatives helped me with loans that I have since repaid so it was all funded out of pocket.

The organization for which I work will switch from BCBS to United effective Sept. 1 of this year. From reading previous threads on this topic, United seems to be more willing to cover oral applicances for OSA than BCBS, but I am not certain. Has anyone out there made a successful claim with United for TAP or Somnodent with United? If so, please share your experiences since I know of at least one person who really wants an oral device and would likely get it if United covers it.

Unfortunately, it will likely take something like a very influential insurance executive or the relative of one getting OSA, not being able to use CPAP, wanting an oral device and experiencing many of the same things from greedy insurance companies that many of us have experienced before it will get much easier. Realistically, I doubt that will happen anytime soon.

Your points are well taken. I also get the impression that at least some medical insurances are not really committed to paying for OA's even if the patient policy states eligibility. They know that, at this point, dental offices are not particularly skilled at submitting medical claims. Instead of helping you, they do everything they can to capitalize on any minor error you may make in submitting the claim to delay payment and wear you down. I feel that more dental offices than you think make a good faith effort to submit claims to the best of their ability, but get discouraged, worn down, and sometimes just plain lied to. Hopefully, in time this will change.
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Re: Tap III and Insurance Question

Postby blueh2o » Wed Sep 12, 2012 2:59 pm

rjoker53 wrote:This is a very important topic. I can safely say we'll continue to see TAP III & other OA insurance threads over the coming years as more sleep apnea sufferers discover the OA option & decide to pursue it. I greatly admire the persistence of any of you that continue to fight for it, esp. in dealing with Blue Cross Blue Shield (BCBS). Yes, I cannot emphasize the importance of using the right codes and other procedures when filing the claim. My experience is that the dental offices either don't have the training/knowledge of the codes and other ways to properly file the claims to have the best shot at coverage or helping is not a priority for them. I realize this is not the case with every dental office and I greatly commend those who go the extra mile to try and help those sleep apnea sufferers who get dental devices from them file successful claims.

I probably gave up too easily after receiving my TAP 3 in Ocotober of 2011. Fortunately, relatives helped me with loans that I have since repaid so it was all funded out of pocket.

The organization for which I work will switch from BCBS to United effective Sept. 1 of this year. From reading previous threads on this topic, United seems to be more willing to cover oral applicances for OSA than BCBS, but I am not certain. Has anyone out there made a successful claim with United for TAP or Somnodent with United? If so, please share your experiences since I know of at least one person who really wants an oral device and would likely get it if United covers it.

Unfortunately, it will likely take something like a very influential insurance executive or the relative of one getting OSA, not being able to use CPAP, wanting an oral device and experiencing many of the same things from greedy insurance companies that many of us have experienced before it will get much easier. Realistically, I doubt that will happen anytime soon.


RJoker,
I have United Healthcare PPO. They just rejected my Prior Authorization for a maxillomandibular advancement (I have an appeal in now). It's specifically excluded in the Certificate of Coverage. Forget that, I just want them to pay for the Out of Network doctor visit. They paid $17 of a $390 bill. When I asked how that was, they said they based their reimbursement on what Medicare covers. So I asked, "if I had Medicare coverage would that be as good as my UHC PPO?" The customer service rep. said "that could be possible". Bottom line, if you can get your employer to go elsewhere for insurance, do it. United Healthcare sucks! Just check online for complaints.
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Re: Tap III and Insurance Question

Postby blueh2o » Wed Sep 12, 2012 3:08 pm

I should also clarify that I believe the UHC PPO also excludes oral appliances. That won't stop me from submitting a claim, using the tips above. Insurance is a scam.
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