Referral Form for OAT

Letter of Medical Necessity & OAT Referral

REFERRING PROVIDER

Dr. Matthew Scarberry

Scarberry Dental Sleep Solutions

2035 Kanawha Terrace | St. Albans, WV

304.727.2222

CODE - E0486 QUANTITY-1

PATIENT

First Name

Last Name

PATIENT PHONE NUMBERS

Cell

Home

Work

INSURANCE COMPANY

Name

Group Number

Account / ID Number

Gender Assignment at Birth

Male

Female

Date of Birth

Age

Patient Address

City

State

Prescribing Physician

NPI

Primary Diagnosis

G47.33 (Obstructive Sleep Apnea)

R06.83 (Snoring)

Secondary Diagnosis (Comorbidities)

Is this Patient Intolerant of PAP or Not a Candidate for PAP Therapy?

Intolerant of PAP

Not a Candidate for PAP

Prefers Not to Use PAP

DURATION OF PAP TREATMENT

Start Date

End Date

Still Currently Using?

Yes

DESCRIPTION OF ORAL APPLIANCE - Oral Appliance Used to Reduce Upper Airway Collapsibility, Adjustable or Non-Adjustable, Custom Fabrication, Includes Fitting & Adjustments.

Please Upload the Following Documents Needed to Proceed with Oral Appliance Treatment.

Medical History & Medications
Current Progress Notes
Diagnostic Sleep Study
PAP Trial Study

Upload Documents

STATEMENT OF MEDICAL NECESSITY - The above patient had a sleep-disordered breathing evaluation. This evaluation confirmed the diagnosis of obstructive sleep apnea. This evaluation confirmed that an ORAL APPLIANCE is medically necessary. Currently, Medicare has a code (E0486) with the following descriptor, “ORAL APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATION and INCLUDES FITTING AND ADJUSTMENTS” Treatment duration will be at least one year and could be required for the remainder of the patient’s life. If you should have any questions, please contact the prescribing physician.