Future Reimbursement In Dental Sleep Medicine To Be Based On Diplomacy And Patient Outcomes



The American Sleep and Breathing Academy (ASBA) is an organization dedicated to enriching our members’ knowledge and skill in the treatment of sleep disordered breathing. Our goal is to provide current evidence based information to our members and enable them to provide optimal treatment for their patients. The ASBA offers Certification to its members as a confirmation of their knowledge, skill and experience. While there are multiple levels of Certification within our organization, the primary goal is to show the industry that our diplomates are able to achieve better patient outcomes and a more successful business overall.

It is very important that a dentist needs certification from an accredited academy because dental sleep medicine must be consistent based on outcomes and the literature. If we look into the future of healthcare in the not so distant future, reimbursement will be factored on credentialing and patient outcomes. The ASBA is a unique organization that emphasizes research and outcome monitoring in combination will contribute to the success of our diplomate members.

The ASBA diplomate will show the medical world that they are a master of dental sleep medicine. Insurance carriers require quantifiable information to show patients and referring physicians that their doctors have higher treatment outcomes; in addition if you are already a diplomate in another academy and become a diplomate of the ASBA you are more likely to receive referrals from local physicians as a double diplomate. This includes but is not limited to compliance monitoring and objective outcomes monitoring which will confirm that an ASBA diplomate provides a certified higher standard of care.

As an ASBA member, you have an opportunity to attend the ASBA review course for diplomacy September 23rd and sit for the exam September 24th in Phoenix, AZ. Register here or call 602-478-9713 for more information.

Certification guidelines include:

  • 40 hours of continuing education in Dental Sleep Medicine, in the last 2 years. This year’s Board Review and Annual Meeting can count towards the 40 hours. Proof must be emailed to psv101@icloud.com before sitting for the certification exam.
  • Submit 10 cases that you personally treated successfully with Oral Appliance Therapy.
  • (Each case submission must be submitted and numbered as cases 1-10, with no names. Names must be whited out!)
  • Three must be severe, that were reduced by at least 50%. Three must be moderate that were reduced by at least 50% and have a treated AHI of less than 10. Four can be mild to moderate with a treated AHI of less than 5.
  • The diagnostic and follow up studies must be administered by a 3rd party diagnostic facility using either HST or PSG., and must be emailed to psv101@icloud.com, by January 15, 2017.
  • Pass the 100 question, certification exam, given on September 24, 2016. Categories for the exam:
  • Basic Sleep Medicine, Oral Appliance Therapy, Polysomnography, Portable Monitors, Surgery, Pediatrics, Complications, CPAP, Imaging
Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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Final Public Listening Session Today! Let Our Voices Be Heard!

truckaccident-300x240                                                                                                                                                    Today at 1:30PM- 3:30PM PST the third and final public listening session will be held at the Westin Bonaventure Hotel and Suites, 404 S. Figueroa St. in Los Angeles. On March 10, 2016 The Federal Motor Carrier Safety Administration and Federal Railroad Administration announced a notice of proposed rule making to receive feedback about any potential sleep apnea regulations. Information on the prevalence of moderate-to-severe obstructive sleep apnea (OSA) among individuals occupying safety sensitive positions in highway and rail transportation, and of its potential consequences for the safety of rail and highway transportation can be solicited at this hearing as well as be submitted online in the form of comments. The 90-day comment period will be ending June 8, 2016.

Through the listening session, interested parties will have one last opportunity to share their views and any data or analysis regarding sleep apnea with representatives of the FMCSA and FRA. As a contributor, you are asked to identify whether you are in the transportation industry or medical profession, but you can choose to remain anonymous. The Agencies will transcribe all comments and place the transcripts in the dockets FMCSA-2015-0419 and FRA-2015-0111.

Previous listening sessions took place May 12 in Washington, D.C., and May 17 in Chicago. Highly prioritized concerns during the sessions have included the cost of sleep studies for drivers and locomotive engineers, the failure of most safety-sensitive transportation employees with apnea to use their CPAP machines and ensuring that any apnea mandates consider safety benefits over costs and driver health.

As ASBA members, we need to provide input on how it is important to driver and public safety to be treated for OSA. For those who are unable to attend in person, the entire proceedings of today’s listening session will be available on the through a live webcast, which can be found here.

Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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New Study Shows That CPAP and Oral Appliance Therapy Come Out Even Par, When Used Equal Amount of Time

Gergen's Orthodontic Lab Sleep Herbst
Gergen’s Orthodontic Lab Sleep Herbst

Maria De Lourdes Rabelo Guimarães and Ana Paula Hermont1



Dental practitioners have a key role in the quality of life and prevention of occupational accidents of workers with Obstructive Sleep Apnea Syndrome (OSAS).


The aim of this study was to review the impact of OSAS, the Continuous Positive Airway Pressure (CPAP) therapy, and the evidence regarding the use of oral appliances (OA) on the health and safety of workers.

Materials and Methods:

Searches were conducted in MEDLINE (PubMed), Lilacs and Sci ELO. Articles published from January 1980 to June 2014 were included.


The research retrieved 2188 articles and 99 met the inclusion criteria. An increase in occupational accidents due to reduced vigilance and attention in snorers and patients with OSAS was observed. Such involvements were related to excessive daytime sleepiness and neurocognitive function impairments. The use of OA are less effective when compared with CPAP, but the results related to excessive sleepiness and cognitive performance showed improvements similar to CPAP. Treatments with OA showed greater patient compliance than the CPAP therapy.


OSAS is a prevalent disorder among workers, leads to increased risk of occupational accidents, and has a significant impact on the economy. The CPAP therapy reduces the risk of occupational accidents. The OA can improve the work performance; but there is no scientific evidence associating its use with occupational accidents reduction. Future research should focus on determining the cost-effectiveness of OA as well as its influence and efficacy in preventing occupational accidents.

Keywords: Continuous positive air pressure, obstructive sleep apnea, occupational accidents, oral appliances, review


The Obstructive Sleep Apnea Syndrome (OSAS) is characterized by repeated collapse of the upper airway during sleep, resulting in nocturnal hypoxemia and fragmented sleep. Associated brain dysfunctions can be expressed, such as abnormal daytime sleepiness and lack of concentration, and these are common causes of traffic accidents.[1,2,3,4]

Several studies have associated OSAS with increased risk of traffic accidents[4,5] and the majority of the researches were conducted among professional drivers. Obtaining data on the frequency of sleep-disordered breathing, nocturnal sleep disruption, and excessive sleepiness among the working population is an important public health problem.[6,7] It is noteworthy that the identification and treatment of snoring and OSAS in workers can potentially reduce the number of occupational injuries, absenteeism, improve productivity, health, and wellbeing of these professionals.[8,9,10,11]

Several well-tolerated and effective treatments for OSAS have demonstrated improvements in the quality of life and reduction in the use of health services and vehicle collisions.[12,13,14] Treatments for OSAS can be clinical or surgical, and the clinical treatment options include behavioral measures, and the use of continuous positive airway pressure device (CPAP) or oral appliances (OA).[15]

The OA are a noninvasive treatment option for patients with OSAS and it is considered less uncomfortable than CPAP.[16] The American Academy of Sleep Medicine recommends the OA therapy for patients with mild-to-moderate OSAS and those with severe OSAS who cannot tolerate CPAP and refuse surgery procedures.[17]

The use of CPAP is indicated as firstline treatment for people with high levels of apnea-hypopnea index (AHI) associated with excessive sleepiness[18] ; however, there are indications that OA improves subjective sleepiness and sleep-disordered breathing.[19]

Randomized trials assessing the effectiveness of OA found that it reduced the excessive daytime sleepiness when compared with patients without treatment.[20,21,22,23,24] Moreover, when the results of CPAP and OA were compared, there was no significant difference between both therapies.[25,26,27,28,30]

A randomized clinical trial presented improvements on energy and fatigue levels and vigilance and psychomotor speed among patients treated with OA when compared with placebo.[20] Other studies also found improvements in neurocognitive function using the OA, which did not differ statistically from the improvements achieved by the CPAP therapy.[26,27]

In 2011, a longitudinal study was conducted with patients with mild-to-moderate OSAS who were randomized regarding the treatment for CPAP or OA. The study showed similar improvement from both therapies regarding the AHI and excessive daytime sleepiness; however, the survey sample was not representative.[31] It is worth noticing that changes in the oral appliances design may contribute to different results, once a study comparing devices with different designs showed differences in the improvement of excessive daytime sleepiness.[32]

The CPAP treatment significantly reduces the risk of accidents in OSAS patients.[33,34,35,36,37] Treatment with OA, in addition to being effective to normalize the respiratory disorders, improved work performance of patients with OSAS.[38] However, it still lacks a more comprehensive way to assess the benefit of OA on driving simulation and real driving performance.[14] This article aimed to revise the prevalence and impact of OSA on work performance, occupational impairments, use of health services, and its economic impact. The cost-effectiveness and effects of the CPAP therapy and especially the role of OA concerning those issues were also investigated.


These were the inclusion criteria used in this article: Articles published from January 1980 to June 2014 concerning patients with a diagnosis of OSA, presenting AHI >5, snorers, upper airway resistance syndrome, age ≥18 years; any study design and the languages were restricted to: English, French, and Portuguese.

Exclusion criteria were central sleep apnea, coexisting sleep disorders, regular use of sedatives or narcotics, preexisting lung disease, and psychiatric illness. Searches were conducted on MEDLINE (PubMed), Latin American and Caribbean Literature Data on Health Sciences (LILACS) and Scientific Electronic Library Online (SciELO), in addition to searches from the references of the identified articles.

The search strategy was performed by combining the following descriptors: Apnea, snoring, sleepiness, mandibular advancement devices, oral appliances, continuous positive air pressure, cost, economics, cost-effectiveness, accident, health care utilization, driving, occupational accidents, occupational injury, traffic, commercial vehicle drivers, and work limitation. The analysis was based on critical readings of the articles content. Subsequently, the common contents were identified, grouped, and tabulated to form the thematic analysis and preparation of a critical discourse.


During the search, 2188 articles were identified, but 2095 were excluded once they did not meet the inclusion criteria, totaling 99 articles included.

Impairments in occupational performance

Sleepiness negatively affects cognitive function, therefore it is assumed that patients with OSAS suffer impairments in labor capacity,[9,39,40,41] by presenting lack of concentration and attention, memory impairment, and changes in the ability to perform everyday tasks and learning. Moreover, the reduced capacity for executive functions such as completing tasks, can cause loss of motivation and initiative.[9,42]

The National Sleep Foundations (NSF) in the United States assessed the sleep of workers and found that those at risk for OSAS had a greater chance of having difficulty when performing cognitive tasks, including problems with concentration and organization and also a greater risk of falling asleep at work, decreased productivity, and absenteeism due to sleepiness.[43] Snoring was also highly associated with excessive sleepiness and work performance impairments.[44]

The sleep-disordered breathing was a common finding among Brazilian professional drivers who presented an OSAS prevalence of 38%. Furthermore, the daytime sleep was fragmented and shorter than nocturnal sleep and more drivers presented extreme sleepiness. It is worth noticing that such deficiencies of sleep can negatively affect performance in driving.[45] Another epidemiological study conducted among Brazilian railroad workers suggested age, body mass index (BMI), and alcohol consumption as associated with an increased risk of developing OSAS and it stressed the need for greater attention to this population, once they are more prone to suffer accidents.[46]

In Greece, the prevalence of sleep-disordered breathing among drivers of rail transport was similar to other studies, but the study reported a low prevalence of drowsy drivers (7.1%). However, this data has to be carefully analyzed once it was used a subjective evaluation criterion by Epworth Sleepiness Scale.[47]

Among a group of American officers, sleep disorder was identified as an ordinary problem and that it was significantly associated with increased risk of health problems, work performance, and safety outcomes; OSAS was the most prevalent disorder (33.6%). Excessive sleepiness was found in 28.5% of the police officers and there was an increase in the prevalence of physical and mental health disorders, including diabetes, depression, cardiovascular disease, and increased risk of accidents.[48]

A study carried out among soldiers identified that 88.2% of the sample were diagnosed with sleep disorders. Insomnia coexisting with OSAS was found in 38.2% of the military and they were significantly more likely to meet criteria for depression compared with control subjects and others with only OSAS.[49] Among young soldiers in Korea, it was found that the prevalence of snoring and high risk of OSAS was 13.5% and 8.1%, respectively. It is worth noticing that this is not a low prevalence considering that the individuals were young and not obese.[50]

It was observed that the treatment of OSAS resulted in the reduction of occupational accidents and improved the performance of employees. Therefore, it is advisable to develop strategies for screening effective treatment of OSAS.[51] Nevertheless, it has been difficult to establish the exact effect of untreated OSAS in real driving and traffic accidents. Driving simulators have been used as a cheaper and safer reproducible way to assess the effect of OSAS on different aspects of driving, but despite the benefits provided, the simulator cannot measure all the aspects experienced in a real-life driving situation.[52]

In Canada, useful data from a study of driving in “real life” were evaluated. Over a period of three years patients with mild, moderate, and severe OSAS had an increased rate of traffic accidents when compared with drivers without this condition and had higher rates of road traffic accidents associated with personal injury.[53] Worse performances in driving simulators among subjects with untreated OSAS was also identified by other studies.[54,55,56] Nonetheless, after treatment with CPAP, there was an improvement in the driving performance.[36,54,55] It is known that the CPAP therapy improves driving performance and can potentially reduce the risk of accidents, but the benefits provided by CPAP depend on treatment adherence.[57]

The results of a study conducted in 2011 suggest persistent impairment in driving simulator during long trips in patients with severe OSAS treated with CPAP. These results support the evidence that some neurobehavioral deficits in patients with severe OSA are not fully reversed by treatment. More controlled studies with larger samples are needed to confirm these findings and further researches should investigate the causes of residual driving simulator impairment among patients with OSAS treated with CPAP and its association with increased risk of vehicular accident on highway.[57]

Test driving simulator was also used to investigate whether OSAS patients had worse labor performance than healthy drivers. The benefits provided by OA and CPAP were also analyzed. The results showed a significantly higher number of lapses in attention among OSAS patients. The total number of lapses of attention was significantly decreased after both therapies, with OA and CPAP, with no significant differences between the two types of treatment.[25]

However, a more comprehensive way to assess the benefits of OA on driving simulation tests, and real-life driving performance are needed to adequately assess its potential role concerning the risk of drowsiness at the wheel represented by OSA.[14]

Another important issue that should be discussed concerning the impairments in occupational performance is related to the international driving licensing legislation. A committee established by the European Commission on sleep apnea and driving has been discussing about directives with an approach to patients with moderate or severe sleep apnea, particularly associated with significant sleepiness. Those patients will be prevented from driving, or at least will be prevented from holding a driver’s license, until the condition is successfully treated.[58]

The driving licenses may be issued to applicants or drivers with moderate or severe OSAS who show adequate control of their condition and compliance with appropriate treatment and improvement of sleepiness, if any, confirmed by authorized medical opinion. Applicants or drivers with moderate or severe OSAS under treatment shall be subject to a periodic medical review with a view to establish the level of compliance with the treatment, the continued good vigilance, and evaluate the need for continuing the treatment.[58]

Occupational injury

Many mental functions are reduced in situations of fatigue and sleepiness.[59] It is estimated that 20% of accidents are caused by drivers’ inattention and sleepiness,[60] and the occurrence of drowsiness when driving is a major risk factor for dangerous accidents.[61] Chronic excessive sleepiness and sleep-disordered breathing were common in a sample of drivers of commercial vehicles in Australia. Sixty percent of drivers had OSAS and 16% had OSAS with excessive daytime sleepiness.[62] Drivers with a high risk for OSAS and a work schedule with little chance of rest reported more daytime sleepiness and poor sleep quality in a study conducted among Belgian truckers[63] and Japanese bus drivers.[64]

In Brazil, 16% of professional drivers admitted having fallen asleep at the wheel; however, this number increased to 58% when it was reported by colleagues. It was observed that respiratory disorders and snoring are some causes of fragmentation or reduction of rapid eye movement (REM) sleep, which could support the hypothesis that REM sleep deprivation can lead to common complaints such as mental fatigue, irritability, and sleepiness among professional drivers.[65]

Nowadays, most European countries have traffic laws directed to sleep-disordered breathing.[7] The driver screening methods should contain questions about drowsiness at the wheel, habitual snoring, and sleep apneas, as well as the Epworth Index and BMI.[7] After an assuredly effective and efficient treatment, including regular checkups for control and evaluation of symptoms, patients are allowed to drive. Nevertheless, during the interim period between the diagnosis and therapy, drivers can still be considered able to drive, but with limitations (eg, drive short distances and avoid driving on major highways or at night.[7,66]

In Brazil, due to the high rate of traffic accidents caused by drowsiness, in 2008, a resolution was approved by the National Traffic Department to reduce the number of accidents caused by drowsiness, fatigue, sleep-disordered breathing, and changes in biological rhythms.[59] Evaluation of OSA was included in this resolution as well as the requirement of new medical and psychological examinations for all professional drivers.[59]

Sleep-related accidents comprise 16%-23% of all vehicle accidents.[67] Many of these accidents could be prevented by treating sleep-disordered breathing.[68] However, drivers with symptoms of drowsiness or sleep-disordered breathing may not report accidents due to concerns of losing their jobs, compromising the results of studies on the association between these disorders and accidents.[62]

A study conducted among long distance truck drivers in the United States found that about 20% of drivers presented symptoms of sleep disorders. Drivers who were working with the same company for over a year were more likely to have daytime fatigue, daytime tiredness, restless sleep, hypertension, and increased BMI.[6] Other studies observed a higher prevalence of OSAS in railway workers than in the general population,[46,47] thus necessitating greater attention to this population, due to the greater propensity for accidents.

A research conducted with presumably healthy working men also identified a significant association between the complaint of excessive daytime sleepiness and the incidence of sleep apnea.[69] In Turkey, 241 long-distance drivers were interviewed about symptoms of OSAS, and occupational history. The drivers who had evidence of OSAS underwent polysomnography. Snoring was detected in 56% of all participants and daytime sleepiness was observed in 26.6%. The prevalence of OSAS was 14.1%. There was a significant relationship between the rate of traffic accidents by professionals/year and AHI, lowest saturation, desaturation index, and arousal index. The disease severity was directly proportional to the risk of accidents.[70]

Snoring, which is one of the signals present in OSAS, has been associated with increased risk for accidents and morbidity. A study conducted in Hungary found that snoring is common in the adult population. Through interviews, the study showed that especially loud snoring with breathing pauses was strongly associated with health impairment, higher comorbidity, daytime sleepiness, and a higher frequency of accidents.[71]

A retrospective evaluation of snoring workers due to suggestive symptoms of OSAS found a significantly higher frequency of occupational accidents among these professionals when compared to the general population of snorers. In this study, all subjects underwent overnight polysomnography in a sleep laboratory and, interestingly, the risk of accidents was high among heavy snorers without apnea and patients with OSAS.[8]

A prospective study found that men who reported both snoring and excessive daytime sleepiness were with an increased risk of labor accidents during the 10 years of follow-up.[72] The high risk of traffic accidents among drowsy drivers was mainly determined by the respiratory effort-related arousals (RERA) than by the presence of apneas and hypopneas.[73] The RERAs are secondary to upper airway obstructions during sleep and can occur in the absence of apneas and hypopneas, causing excessive daytime sleepiness.

Studies using the esophageal pressure measure were performed in habitually sleepy drivers and drivers without this condition. Sleepy drivers with apnea had higher accident rates in five years than drivers in the control group. Nevertheless, a high rate of RERA, but not sleep apnea, was still a risk factor among drivers habitually sleepy. These findings confirm the importance of identifying RERA in routine examinations in sleep laboratories.[73]

Just like it occurs with civilians, excessive sleepiness is a risk to the safety of military that operate dangerous vehicles, machinery, or carry firearms. Military with untreated OSA are also at risk for suffering from decreased mental alertness and decreased cognitive function due to drowsiness. Military with mild-to-moderate OSA and upper airway resistance syndrome (UARS) often have abnormal results in the Maintenance of Wakefulness Test and therefore have a pathological tendency to fall asleep. A study conducted in 2009 among military personnel identified that 32% of the sample had UARS and 68% OSA.[74]

Effectiveness and efficacy of CPAP and oral appliances

The physician must diagnose sleep apnea and evaluate the patient’s risk for injuries. The patient should be informed about the risks and an appropriate treatment should be instituted. In addition, the doctor should provide a follow-up plan to determine if the treatment has decreased the patient’s risk for accidents.[75]

Although many investigations have pointed out that treatment of primary snoring and OSAS with CPAP or OA contributes to the reduction of vehicle and labor accidents,[12,33,34,36,76] this review did not find any studies evaluating the effectiveness of OA regarding this outcome.

Like several other medical treatments, the efficacy of CPAP or OA depends on the degree of identification of OSAS and the degree of adherence to the treatment among the diagnosed individuals.[35] Treatment with CPAP reduces the risk of accidents because it is used by the patient.[77] Nonetheless, adherence to CPAP continues to be a major problem when treating OSAS, although more recent data suggest that adherence may have improved in recent years. However, a recent study found that only 5% of professional drivers diagnosed with OSAS showed adequate adherence to CPAP.[35,78]

It is important to include the patients in the treatment decision, offering more than one type of therapy for patients with OSA. Despite the residual apneas with the use of OA, or the highest rate of effectiveness of CPAP in reducing AHI, the similarities between the results of such treatments may be related to the hours of use per night. The OA which are considered to have partial efficacy, when used for prolonged hours may lead to similar outcomes when compared with CPAP.[79]

The ability to pre-select suitable candidates for either treatment is important. Although some predictors of success with OA have been evaluated, further studies are needed to better predict which patient will have a higher level of success with the OA therapy.[79] Less obese patients with mild sleep apnea and certain craniofacial characteristics such as mandibular retrognathia proved to be good candidates for the OA therapy.[80]

When analyzing the economic impact of OSAS, it was highlighted that there was a lack of clarity concerning the epidemiology of accidents in patients correctly treated with CPAP. Furthermore, it was suggested that future studies are needed to evaluate the improvement in the labor activities of OSAS patients before and after treatment, as well as studies evaluating the cost-effectiveness between surgical and clinical treatments.[10]

Most studies regarding the adherence to OA use subjective measures to evaluate the therapy compliance.[81] Nevertheless, a study conducted in 2012 objectively evaluated the use of OA among patients undergoing therapy for OSA by means of a heat-sensitive microsensor, which was attached to the OA. The overall mean rate of OA use was 6.7 ± 1.3 h per day with a regular users’ rate of 82%. Despite not having a statistically significant difference between the self-report and the use of microsensor, the safety and feasibility of using this device to objectively measure the OA’s compliance was highlighted.[82]

Although, according to a systematic review, many studies have demonstrated the effectiveness of OA in reducing daytime sleepiness and improve the neurocognitive function,[19] the Federal Motor Carrier Safety Administration does not recommend the use of the OA in the treatment of OSAS among professional drivers, once there is no scientific evidence associating the reduction of accidents by using these devices and it is difficult to assess the patients’ treatment adherence.[83] Furthermore, an updated version of the Thoracic Society Clinical Practice Guideline recommended the use of CPAP to reduce accidents, but again the OA were not listed due to lack of scientific evidence about the effects of this therapy on the risk of accidents.[84]

The OSAS treatment options may become limited by the conditions of the work environment. The diagnosis of sleep-disordered breathing may affect the deployable strength of the military personnel due to the difficulty they might face concerning the use of CPAP.[74] Military deployed in desert environment are at a risk of inhaling airborne particulate matter that can harm their health. In this condition, the CPAP therapy can facilitate the inhalation of these particles. Therefore, alternatives to solve this problem such as using foam filters have been tested.[85]

Economic impact of OSAS

Obstructive sleep apnea affects the daily lives of millions of people around the world and presents a growing economic impact. The evidence linking OSAS with various public health problems such as obesity, diabetes, depression, cardiovascular disease, and accidents has increased.[10]

It is estimated that in the United States, the total costs attributable to sleep apnea-related accidents is quite high. In 2000, 1400 people died due to vehicular collisions and in 2004 these accidents had a cost of $ 15.9 billion. With regard to the management of accidents, it is estimated that the treatment with CPAP for all drivers who suffer from OSAS would be of $ 3.18 billion. Even taking into account a treatment efficiency of only 70%, there would be a reduction of $ 11.1 billion in collision costs and 980 lives would be saved per year.[13] The literature suggests that treating 500 patients for three years would result in savings more than $ 1,000. 000.[68]

A more recent analysis of OSAs’ treatment showed significantly lower costs of the treatment plan. In addition, it was also observed fewer disability claims; cost reduction for disability and fewer lost days of work.[86] A prospective study compared the effects of OSAS between men and women during 1994-2005. An increased risk of absenteeism in subjects with sleep apnea was observed. In women, the major risk was present five years before diagnosis, whereas in men the major risk was observed one year before the diagnosis of OSAS.[87]

Education campaigns encouraging members of health plans to seek specific treatment for sleep-disordered breathing resulted in substantial savings. Two years after the education campaign started, it was computed savings of U.S. $ 4,900.00.[88]

Dentists can play an important role in accident prevention through the detection of risk factors by screening their patients for OSAS, evaluating oral/jaws anatomical features, and screening for sleep disorders during the anamnesis.[14]

Use of health services and resources

Untreated obstructive sleep apnea predisposes patients to various morbidities and consequently increases the use of health services.[10,12,89,90,91] The risk assessment of OSAS among workers can help to reduce the national health care burden.[51] Evidence suggests that patients with untreated sleep apnea require a greater amount of health resources. Moreover, adherence to treatment in patients with OSAS results in a significant reduction in hospitalizations and medical applications.[92,93]

In 2013 a study comparing the health effects after one month of CPAP and OA therapy identified that despite the CPAP therapy was more effective in reducing the AHI, the therapy with OA had greater adherence, hence both therapies showed similar results.[94]

Cost-effectiveness of OSAS treatment

Concerning CPAP therapy, studies in several countries have evaluated its cost-effectiveness[12,95,96] Some patients have to try more than one treatment option before control of OSAS is reached. Treatment should be individualized and supported by scientific evidence, and the evaluation of cost-effectiveness is also required. Information about the therapy cost is important for the governments, transport, industry, and insurance agencies to plan actions to decrease the economic impact of untreated OSAS.[97]

Data on types of treatment for snoring and OSAS suggested that therapy with OA had lower costs when compared with other treatment modalities.[15] Nonetheless, it has not been evaluated yet the use of OA associated with reduced risk of vehicle and labor accidents. Further studies should evaluate from a social perspective the loss of work productivity, increased absenteeism, insurance, and costs and assess the use of OA in preventing occupational accidents.[10]

The cost-effectiveness of CPAP was compared with the OA therapy and lifestyle advice using a method of quality-adjusted life year (QALY) in a life perspective. On average, CPAP was associated with higher costs than other therapies. However, in another analysis CPAP was more profitable than OA. Therefore, regarding adults who suffer from moderate or severe symptomatic OSA it was concluded that CPAP has better cost-effectiveness when compared with OA and lifestyle advice.[98]

The OA are now widely prescribed for the treatment of OSAS, either as a primary or as an alternative measure to those patients unwilling or unable to tolerate CPAP therapy. Although CPAP has been shown to be more effective than OA[19] and highly cost-effective,[36] there are increasing evidences that OA improve drowsiness, blood pressure, and indices of sleep-disordered breathing.[79] Moreover, many patients who respond to both treatments generally prefer to use OA.[16]

Despite the limited evidence on the cost-effectiveness of OA, through this literature review it can be observed that OA are economically less attractive than CPAP, but remain as a cost-effective treatment for patients who do not want or do not adhere to treatment with CPAP.[99]


This review highlights the fact that OSA is a prevalent disorder among works, leads to increased risk of occupational accidents, greater use of health services, and has a significant impact on the economy.

The CPAP therapy reduces the risk of occupational accidents. Furthermore, it has been shown to be cost-effective, improve the work performance, and reduce health burdens. Regarding OA, despite showing an improvement in work performance, there is no scientific evidence of occupational accidents reduction. Moreover, there is limited evidence of its cost-effectiveness and its effect on reducing the use of health services.

Due to the lack of evidence regarding the use of OA for occupational accidents, future research should focus on determining the cost-effectiveness, influence, and efficacy of these devices in preventing occupational accidents among workers who suffer from OSA.


Source of Support: Nil

Conflict of Interest: None declared.


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Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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ASBA Is The Only Academy Fighting For Dental Rights In The Sleep Apnea Arena-ASBA Receives Support From Congresswoman Anna G. Eshoo Written By David Gergen

Congresswoman Anna G. Eshoo and Dr. Alpher
Congresswoman Anna G. Eshoo and Dr. Alpher

The Georgia’s new legislation now says, “Depending on the diagnosis of the type and severity, one possible treatment option for obstructive apnea is the use of oral appliances.  The design, fitting, and use of oral appliances and the maintenance of oral health related to the appliances falls within the scope of the practice of dentistry.  The continuing evaluation of a person’s sleep apnea, the effect of the oral appliance on the apnea , and the need for, and type of, alternative treatment do not fall within the scope of dentistry.  Therefore, the prescribing of sleep apnea appliances does not fall within the scope of the practice of dentistry.  It is the position of the Board that a dentist may not order a sleep study. Home sleep studies should only be ordered and interpreted by a licensed physician.  Therefore, only under the orders of a physician should a dentist fabricate a sleep apnea appliance for the designated patient and conduct only those tasks permitted under OCGA title 43, chapter 11. (Adopted 4/1/2016)”

This is very disappointing for dentists in Georgia. Let’s look at the interpretation of this new law. Does it mean a dentist will no longer be able to titrate their appliance by using a home sleep test? It surely means a dentist cannot refer out to a sleep testing company such as Complete Sleep, Snap or Easy Sleep or hand out an HST to one of their patients and have a Board Certified physician do the read and diagnosis. To the ASBA this is horrible news and we will be fighting it with all of our resources. You will be pleased to know that just yesterday, ASBA Board Member and Diplomate Dr. Elliott Alpher was in Washington D.C. alongside Congresswoman Anna G. Eshoo discussing this very topic and transportation.

David Gergen, Dr. Alpher, Marty Russo, Roy Green, Lieutenant Holmes, Mark Walczak, asba
David Gergen, Dr. Alpher, Marty Russo, Roy Green, Lieutenant Holmes, Mark Walczak

Dr. Elliott J. Alpher, Diplomate to and representing the American Sleep and Breathing Academy and Congresswoman Anna G. Eshoo (DCalif.), Ranking Member of the Energy and Commerce Committee’s Subcommittee on Communications and Technology for the 114th Congress met today to ask her support on proposed rulemaking for screening, diagnosing, treating and tracking compliance of Obstructive Sleep Apnea (OSA) in individuals occupying sensitive positions in highway and rail transportation.

The Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) have requested data and information concerning the prevalence of moderate-to-severe obstructive sleep apnea (OSA) among individuals occupying safety sensitive positions in highway and rail transportation, and on its potential consequences for the safety of rail and highway transportation.

Many mental functions are reduced when an individual experiences fatigue and sleepiness. It is estimated that 20% of accidents are caused by drivers’ inattention and sleepiness, and the occurrence of drowsiness when driving is a major risk factor for dangerous accidents. Chronic excessive sleepiness and sleep-disordered breathing are common in commercial vehicles drivers.

Dr. Alpher Washington D.C.
Dr. Alpher Washington D.C.

“OSA is a prevalent disorder among workers, which increases the risk of occupational accidents and has a significant impact on public safety. Fortunately, many of these accidents could be prevented by screening and treating sleep-disordered breathing with the resources and technology available…we are grateful to have Congresswoman Eshoo’s support on this matter,” says Dr. Alpher.

Dr. Alpher, one of the District’s most experienced specialists for sleep and jaw disorders, on staff at George Washington University Hospital and Georgetown University Hospital, has been known as a leader in the treatment of sleep disorders and jaw pain for 25 years. Dr. Alpher has pioneered a conservative, non-invasive approach utilizing computerized and verifiable diagnostic methods to treat TMD, snoring and sleep apnea. This method of treatment has proven to be greatly successful and is highly regarded as the first method of choice by physicians and patients.

Dr. Alpher was also responsible for heading a delegation to the Medical Advisory Board (MAB) to introduce the new technology of compliance chips in oral appliances to treat and monitor sleep apnea and snoring of truckers and other transportation personnel. In addition, he earned the status of Diplomate of the American Board of Craniofacial Pain & Dental Sleep Medicine in October 2013 and serves as a board member. Dr. Alpher is a Diplomate of the American Academy of Pain Management, Life Member of both the American Dental Association and the District of Columbia Dental Society. Dr. Elliott Alpher says, “The ASBA is the only academy fighting for the dentists’ rights in the sleep apnea arena and the efforts will become stronger as the American Sleep and Breathing Academy grows. The more members we have the more firepower we’ll have. I am so pleased that I have joined this academy because this is the only academy making a huge difference in my humble opinion. We are so blessed to have former Congressman Marty Russo as our ally.” Dr. Elliott Alpher was elected to the ASBA Hall of Fame for his lifetime achievements in the field of dental sleep medicine. If you are a concerned dentist about your rights, join the American Sleep and Breathing Academy at americansleepandbreathingacademy.com.

Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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Oral Appliances And Positional Therapy With An AZ Cardinal Mark Walczak Story


For patients who refuse or fail CPAP, several alternative therapies may be considered. And recently, some providers are treating appropriate candidates with several alternative therapies used simultaneously to achieve better outcomes.

The use of positional therapy, a behavioral strategy to prevent patients from sleeping in the supine position when they have a positional component to their obstructive sleep apnea (OSA), along with oral appliance therapy (OAT) is a growing trend among sleep medicine providers and can aid patients on their journey to healthy sleep.

Who Is a Candidate?

To determine who is a good candidate for this combination therapy, a review of a patient’s records is a good place to start, providers say—specifically, all of the patient’s sleep studies should be thoroughly reviewed. “Percentage of time spent sleeping supine and supine AHI [apnea-hypopnea index] are the critical values necessary to determine if positional therapy will benefit the patient,” says David Barr, DDS, a dentist at the Koala Center for Sleep Disorders in Wausau, Wis. Barr, a member of the American Academy of Dental Sleep Medicine and a diplomate of the American Sleep and Breathing Academy, says patients who spend a great deal of time sleeping supine and have a significantly higher supine AHI can typically benefit from positional therapy.

Kelly A. Carden, MD, staff sleep physician at Saint Thomas Medical Partners-Sleep Specialists and secretary/treasurer of the American Academy of Sleep Medicine, says she typically determines if a patient is a suitable candidate at the time of the efficacy study for the oral appliance. Carden explains, “In my opinion, an efficacy evaluation is ideally performed as an in-center polysomnography (PSG), wherein the position of the mandible is calibrated in an effort to suppress the apnea-hypopnea index (AHI) below 5 events per hour of sleep.”

Implementation in Care

Deciding when to prescribe the combination therapy of OAT and positional therapy varies based on a patient’s unique needs and responses to other therapies. Carden, who has been prescribing combination therapy of different kinds since her sleep medicine fellowship, says combination therapy is best done when an individual treatment has failed. She employs a variety of therapeutic combinations, including OAT with positional therapy, OAT with positive airway pressure (PAP) therapy, and PAP with positional therapy.

“My motto is to ‘decorate the patient as little as possible’ no matter how I am managing the sleep apnea. If the oral appliance, or PAP, appropriately treats the patient’s sleep apnea without additional intervention, then that is ideal,” says Carden. “Thus, in my practice, I tend to discuss combination therapy when a primary therapy fails to control the sleep apnea alone—for example, persistent OSA despite maximal advancement of the oral appliance or when the primary treatment alone is intolerable.”

Barr has employed positional therapy in combination with OAT to patients for 9 years. “Typically, I have been introducing positional therapy with vibro-tactile devices after I have reduced the overall AHI with appliance therapy and still have significant supine AHI,” says Barr. “I have had a small sample of position-dependent OSA patients that I have given a trial with the vibro-tactile device prior to OAT, some with very positive results.”

Rodney E. Willey, DDS, DACSDD, DASBA, CEO of the Koala Center for Sleep & TMJ Disorders, says, “A PSG or home sleep test (HST) will both indicate if there is a positional component worsening the OSA in a specific position. We typically will treat with a mandibular repositioning appliance (MRA), adjusting it to the optimum position. At that point we will order an efficacy PSG or HST to prove its efficiency.  We would then consider positional therapy if and when it is appropriate.”

Benefits of Combination Therapy

According to Barr, positional combination therapy can have a significant improvement in patient outcomes. This is particularly evident in patients who are CPAP intolerant and do not respond to OAT due to positional obstructive sleep apnea (POSA). Barr says, “As many as 70% of patients diagnosed with OSA are position-dependent. Positional combination therapy can result in better management of OSA patients than would be possible with OAT alone.”

What compliance rate does this combination therapy typically have? We’re not sure yet. “Time will tell on whether requiring a patient to use two devices will affect their compliance rate versus patients who are only required to use one device. So far, asked patient acceptance has been very good,” Barr says, noting that some positional therapy devices objectively track compliance (whereas most oral appliances do not, though the technology is available).

The Night Shift from Advanced Brain Monitoring is one such POSA device that objectively tracks compliance. Barr has been using it with patients for the past 18 months. “The device monitors compliance, enabling the user or the clinician to determine how often the device was used, and its impact on sleep efficiency, awakenings per hour, time and percent time supine, and overall, supine and non-supine percentage time snoring > 50 dB,” says Dan Levendowski, president and co-founder of Advanced Brain Monitoring. In a study published in the Journal of Clinical Sleep Medicine, Levendowski says the treatment effect of the device included significant reductions in cortical arousals, awakenings, stage N1 sleep and snoring, and reported symptoms of depression.1

According to Willey, who has been treating sleep apnea since 2010, compliance is dependent on the patient. “Some patients adapt easily while others find it too bulky and discontinue use of the positional therapy,” he says. “Combination therapy can be very effective when applied at the appropriate times. Like many treatment modalities in medicine, patient selection is imperative, as it does take a compliant patient for this to work.

“When there is a positional component, it can be quite beneficial. Most of the time, a patient’s AHI is less when they are not in the supine position. If the MRA doesn’t eliminate the obstructive airway completely, then adding positional therapy can be quite effective.”

NoPap Pillow Company senior consultant Julia Worrall, RN, and cofounder Kevin Vargas, say, “The effectiveness of oral appliance therapy is greatly influenced by sleep posture. By training the patient to sleep laterally, there is less ‘pull’ on the mandibular advancement device, less pressure on anterior teeth, greater efficacy in overall AHI reduction, and improved compliance.”

Insurance Coverage

Insurance coverage for this combination therapy is not guaranteed, according to Carden, who encourages patients to do the research to understand the financial costs. “Insurance coverage for the various treatments for sleep apnea varies substantially from company to company and from policy to policy. I encourage patients to contact their insurance carrier so they understand the financial impact of treatment,” says Carden. “I will say, however, that my patients often report that coverage specifically for a positional sleeping device is limited.”

Barr also finds that payors have not yet begun to cover this combination therapy. However, if the positive benefits of the joint therapy can be shown, he says perhaps coverage will soon follow. “I have not been able to get insurance reimbursement for this type of combination therapy yet. I charge my normal appliance fee plus $350 for the Night Shift,” says Barr. “I believe that there will be much debate about the appropriateness of beginning OSA treatment with a vibro-tactile device. If it can be shown that the AHI of a severe OSA patient can be reduced to the moderate or mild level with a vibro-tactile device, will that patient be approved for treatment with OAT?”

Products to Consider

In addition to Night Shift, there are a number of options available for clinicians who wish to prescribe positional therapy. These include Slumberbump, a positional belt worn around the chest designed to keep patients comfortably on their sides. “Slumberbump works in sync with other treatment methods and keeps patients in a side-sleeping position, which can help increase the effectiveness of oral appliance therapy,” according to Shad Morris, DMD, CEO of Slumberbump. “Positional therapy is one piece of the puzzle as we work to solve some complicated sleep disorders, but it’s a valuable and complementary piece.”

David Gergen, CDT, executive director for the American Sleep and Breathing Academy, says, “For the past 6 years I’ve been traveling the country working with dentists and physicians to help former NFL greats with their sleep disorders. We have put several players on CPAP, several hundred on oral appliances, and a couple on combination therapy. The latest innovation to our campaign is positional therapy. Using the Slumberbump in combination with an oral appliance has been extremely effective.”

The NoPap Positional Pillow from the NoPap Pillow Company is another option. It is a half body pillow designed to help the user stay in a lateral sleeping position during sleep. “When used properly, the two-sided support minimizes tossing and turning and prevents them from rolling onto their back. It combines the comfort of an L-shaped side sleeper pillow with the support of a back wedge pillow,” say Worrall and Vargas.

Designed by board-certified sleep physician Joseph Crocetti, DO, the Zzoma Positional Device is another option. Available via prescription, it is a positioner worn around the upper torso to restrict patients from moving from the lateral to supine position.

An over-the-counter option developed by a sleep apnea patient is Rematee, which sells a Bumper Belt and Anti-Snore Shirt.

Becky Simmons, RRT, BSRT, clinical respiratory consultant for Contour Products, says the company’s CPAPMax Pillow includes a variety of features including an orthopedic contoured design intended to open up the user’s airway, removable layers for pillow height adjustment, and side cutouts to help reduce leaks and noise. “If the patient is a side or supine sleeper, the pillow creates better neck and head alignment to promote a more patent airway. This would assist in a proper fit of the oral appliance and could lessen the obstruction from soft tissue,” Simmons says.

Keeping Options Open

Future research is needed to provide further evidence supporting the use of OAT and positional therapy, but manufacturers and sleep medicine providers have already seen the positive impact of this joint therapy in patient outcomes. “I continue to prescribe combination therapy based on feedback from patients. It is also nice as a practitioner to be able to provide treatment options for my patients,” Carden says. “I encourage practitioners to keep all options in mind for the treatment of sleep apnea so that treatment can be tailored to the individual. Positional therapy and combination therapy should be in their armamentarium.”

Overall, the implementation of this combination therapy may allow for more options for patients with OSA. “For many years, sleep disorder treatments have been one dimensional. The most exciting advances in sleep medicine are coming from the…combination of therapies for a more comprehensive treatment approach,” says Morris.

Ref: http://www.sleepreviewmag.com/2016/05/combination-positional-therapy-oral-appliance/

David Gergen CDT

I have been in the sleep therapy field for over 20 years. In that time I have witnessed the effect on patients of what I can only call an over reliance on CPAP therapy in treating OSA. Many of my close friends are retired NFL players like Roy Green, Carl Eller, Derrek Kennard, Markus Allen, Eric Dickerson and Mark Walczak who have tried CPAP but found themselves unable to comply with their prescribed therapy. Pro Player Health Alliance was founded to help these icons of the NFL share their experiences and perhaps help patients find therapy that will help them maintain their health and get a good nights sleep.

I am particularly struck by the story of Mark Walczak who has suffered with sleep apnea for many years. After undergoing an in lab sleep study it was shown that Mark had an AHI (Apnea Hypopnea Index) of 62. This is classified as severe sleep apnea “a big guy with a big sleep problem”. Mark was prescribed with CPAP and tried to wear it but was unable to make the therapy work for him.

Studies indicate that CPAP compliance is very low and is dependent on great coaching and highly engaged medical team that work a wide range of patient interfaces and desensitization protocols. This is all in an effort to help the patient adjust to wearing a mask at night with a column of pressurized air blowing into the airway. The sound of the devices and the effort to maintain a clean and effective device, all this combines and contributes to reduced compliance rates. Mark ended up a casualty of this process as do about 50% of patients who start the process according to recent studies.

As part of his journey to healthy sleep he met with Dr Roger Briggs DDS from Scottsdale AZ.  Dr Briggs mad a Herbst sleep appliance for Mark. The Herbst appliance reduced Marks snoring and his sleep apnea to a moderate  level (AHI 17)  however it was not completely eradicated and with further testing it was shown that there was now a significant positional component. The decision was taken that a SlumberBump positional therapy device would be added to Mark’s sleep time ritual.

SlumberBump is a very simple device that is worn around the chest to help position the patient on their side while sleeping. Studies indicate that positional therapy is as effective as CPAP in mild sleep apnea patients.

In combination Mark Walczak wears a Herbst mouth piece and a Slumberbump to bed and his AHI as registered with a sleep study went from untreated AHI of 62 all the way down to an AHI of  1. This took some time, and there were trained dental and sleep clinicians monitoring and guiding the process. I would say that the best part of this approach is that the patient has control over how often how much and understands their condition so much better.

I have to say oral appliance therapy in combination with body position therapy with a SlumberBump is a winner in my book.

Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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Medicare and Private Insurers Raise Rates for Sleep Apnea Dentistry

Sleep therapy continues to receive scrutiny by regulators and payors. Centers for Medicare and Medicaid have been monitoring patient outcomes and clinical yield for patients. There has been no formal announcement as to their findings however CPAP reimbursement continues to be cut while Oral Appliance Therapy reimbursement has officially been increased by Medicare. Revenue from code E0486 has doubled in recent months according to reports by ASBA members, Industry leaders predict that private insurance will follow Medicare reimbursement guidelines.
 Supporting this trend is the recent announcement by Cigna the first private insurer to develop a national policy for Oral Appliance Therapy, settling on $2500 as a bundled fee. In other regions fees have increased by 25 to 100%. Jurisdiction “D” reimbursement rates has remained unchanged.
 Insurers are expected to work with industry to monitor outcomes data to balance revenue and patient care expectations. It is also very significant and important to note that evidence of post graduate training and Diplomacy has become a method that some insurers use to deny insurance claims (this is new and bears watching).
 The American Sleep And Breathing Academy continues to monitor insurance reimbursement, and policies through its relationships with Washington DC insiders like Congressman Marty Russo and others.
 “In June of 2015 the ASBA was the first organization to warn Dentists of the risk to using the “S” code for billing TMJ Splints. Advance notice of this change saved ASBA members thousands of dollars in hard costs associated with billing errors and uncollected revenue.” – David Gergen CDT
 The latest opportunity identified by the American Sleep And Breathing Academy team of lobbyists is a new government protocol for chronic care management. CCM has the potential to contribute a strong revenue stream for sleep apnea dentists in 2016. The physician who developed the Chronic Care Program spoke at the Sleep and Wellness conference in Scottsdale AZ April 15 and 16. 
CMS Bets on Oral Appliance Therapy a blog post Gergensortho.com
A running discussion for the last 6 years here at Gergens Orthodontic Lab has been the CPAP as Gold standard of sleep therapy vs Oral Appliance therapy debate. These discussions usually go for hours and have gone on for years. The strongest debate has been between David Gergen President of Gergens Orthodontic Lab and Executive Director of American Sleep and Breathing Academy (ASBA) and Randy Clare who supports CPAP. Gergen knows CPAP has its place and time in the sleep world, but strongly feels that the oral appliance will surpass CPAP as the go-to treatment within 10 years. Clare would debate if that’s the case, respiratory techs will be managing the oral appliance patients not the dentists. Back and forth compliance vs treatment efficacy. David Gergen has been back and forth to Washington working with congressman Marty Russo trying to get some traction within the federal government on this issue.
The key point of distinction of course is what drives medical care in the United States is reimbursement. The story for CPAP in the reimbursment arena since competitive bidding became an issue has slowly restricted access to care and fed a consolidation of providers. Fewer providers to provide care and the care they can afford to provide is less personal which results in lower compliance rates which results in lower reimbursement. January 1 2016 CMS cut CPAP reimbursement by 25%. Will this affect a diagnosed OSA patients ability to get great care of course it will.
On the other side of the ledger Oral Appliance therapy has not been a focus for CMS. The OAT program has been way underfunded. This has made access to oral devices for sleep apnea difficult for medicare patients. Dentists were not finding it easy to provide care for these patients because reimbursement was so low. January 1 2016 CMS raised reimbursement for OAT to $3700 in jurisdiction B (see attached EOB) If you don’t know your jurisdiction for medicare I have also added a map for your use.
I expect that this will increase access to care significantly. I feel it indicates a trend and perhaps insurers are ready to consider higher compliance rates and better return on sleep therapy dollars. After all the dental team sees the patient at minimum every six months which is a much better way to manage a lifelong condition with severe health implications.
Alan Hickey

Alan Hickey

Publisher of Sleep Diagnosis and Therapy Journal the Official publication of the American Sleep and Breathing Academy, the Journal is a clinical and technical publication for dental and medical professionals.

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