The agency covers the purchase of a mandibular advancement device for a client when the provider determines that the use of a continuous positive airway pressure (CPAP) device is medically contraindicated or the client cannot medically tolerate a CPAP device. Prior authorization is required for all eligible clients.
(1) The agency considers a mandibular advancement device to be medical equipment subject to the same billing requirements, restrictions, and limitations as other medical equipment according to chapter 182-543 WAC.
(2) For clients:
(a) Who have natural dentition, the agency pays for one custom-made mandibular advancement device every five years. The client must:
(i) Complete a face-to-face evaluation with a sleep medicine physician in an agency-designated center of excellence (COE) prior to sleep testing;
(ii) Be diagnosed with obstructive sleep apnea (OSA) using a clinical evaluation and positive attended polysomnogram (PSG); and
(iii) Meet the sleep testing criteria described in WAC 182-552-0400.
(b) Age 20 and younger, providers must follow the rules for the early periodic screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.
(3) The prescriber must keep the following in the client's record:
(a) Documentation of a CPAP trial lasting at least six consecutive months; and
(b) A description of why CPAP failed or an explanation of why CPAP is not the appropriate treatment.
(4) The mandibular advancement device must be titrated by a licensed provider who has documented experience in titrating these devices.
(5) The mandibular advancement device must be provided and billed by a licensed dentist who:
(a) Holds a certification in dental sleep medicine from the American Board of Dental Sleep Medicine (ABDSM); or
(b) Is the dental director of a dental sleep medicine facility accredited by the ABDSM; or
(c) Has completed agency-recognized continuing education in dental sleep medicine provided by the ABDSM or a comparable organization within the two years prior to providing the mandibular advancement device.
(6) The agency evaluates requests for authorization for mandibular advancement devices that exceed the limitations in this section on a case-by-case basis in accordance with WAC 182-501-0169.