Sleep Apnea and Sleep Appliance Medical Necessity Letter
To Whom It May Concern:
______________________ was recently seen in my office and presented the following
_____________. ___________________ has a body mass index of _____ and a neck
circumference of ______. In addition to the symptoms, a BMI over 30 and neck size
over 16” are indications of sleep apnea. The patient was given an Epworth Sleepiness
Scale and scored ______ which indicated an average amount of daytime sleepiness.
These symptoms indicate there is a high probability that she/he has sleep apnea.
______________________was referred to _______________________ for an overnight
(patients’ name) (name of sleep lab)
Polysomnography evaluation. The enclosed report shows a diagnosis of (Mild/Moderate/Severe)
Obstructive Sleep Apnea.
______ Respiratory Disturbance Index (RDI)
______ Apnea Hypopnea Index (AHI)
______% Minimum Oxygen Saturation Level
_____________________________ has exhibited a preference not to use CPAP
but has chosen to accept the prescribed therapy of an oral appliance. Having been informed of other treatment options including surgery, lifestyle modification and oral appliance therapy the patient would like to treat his obstructive sleep apnea with an oral airway dilator appliance.
I recommend oral appliance therapy to treat the patient’s Obstructive Sleep Apnea and request that Dr. Leland Wilhoite fabricate such a device for our patient.