Treatments

Oral Appliance Therapy Rx & Medical Necessity Form for Medically Diagnosed Obstructive Sleep Apnea

Requesting Physician's Name:

Organization:

Phone:

Fax:

Patient's Name:

DOB (Date of Birth):

Patient's Contact Number:

Notes:

Diagnosis:
Obstructive Sleep Apnea - ICD G47.33Hypersomnia due to Sleep Apnea - ICD G47.10Sleep Apnea/Sleep Related Breathing Disorder,Unspecified - ICD G47.30 (UARS)Sleep Apnea, Other, Unspecified - ICD G47.30CPAP IntoleranceOther

Patient has Diagnostic Sleep Study (without CPAP or OA):

Date of Study:

Respiratory Disturbance Index (RDI):

Apnea Hyponea Index (AHI):

Lowest Desaturation (SpO2):

Statement of Medical Necessity

I am referring the above patient to Dr. Srujal Shah, DDS, DABDSM because I believe it is Medically Necessary for him/her to be fitted for a custom fitted oral appliance (E0486).

The above patient had undergone a sleep study and has been diagnosed with obstructive sleep apnea (OSA). According to the American Academy of Sleep Medicine guidelines, oral appliance therapy is a treatment option for OSA. If a CPAP intolerance adavit is attached, it is because this patient could not tolerate CPAP.

Physician's Signature:

Date:

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