Please include a copy of the patients sleep study, an RX stating the patient is CPAP intolerant, and
the patients demographic sheet.
STATEMENT OF MEDICAL NECESSITY
This above patient has undergone a sleep study for a sleep related breathing disorder. This evaluation confirmed that an
Oral Appliance is medically necessary. Oral Appliance Therapy (OAT) is used as an alternative to surgery at this time and
or CPAP, as this patient could not tolerate CPAP or does not feel he/she will be able to tolerate CPAP.
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