By Jordan Stern, MD, CEO and Medical Director
Disability Benefits for Sleep Apnea are Challenging but Possible
While Sleep Apnea is a condition that impairs one’s ability to lead a healthy life, many patients want to know if the Social Security Administration (SSA) will provide benefits if you suffer from Obstructive Sleep Apnea (OSA). The SSA does not consider Sleep Apnea a disability, but it recognizes that severe Sleep Apnea leads to symptoms that qualify for benefits–namely heart diseases; breathing disorders; or mental issues. Your first step is to get tested and treated for Sleep Apnea by a Sleep Specialist like BlueSleep. The success rate for treatment is high, thereby precluding benefits, but some people with severe Sleep Apnea qualify for benefits.
You Need a Medical Diagnosis
Lawyers specializing in disability law will help you navigate the SSA requirements, but we know that Sleep Specialists, Cardiologists, Mental Health providers, and other medical doctors have an important role in your case. To prove your medical case, you must have a medical diagnosis of Sleep Apnea that’s severe enough to keep you from working. The SSA requires that you’ve had your disability for at least 12 months in the past, or that doctors predict you’ll have the disability for at least 12 months. So, the first requirement is to get tested for Sleep Apnea by a medical doctor.
You Need Medical Evidence of a Disability
At BlueSleep Sleep Clinic, we record your medical history and symptoms and offer a home sleep test to gauge the severity of your problem. For treatment, we may recommend Continuous Positive Airway Treatment (CPAP) or Oral Device Therapy (OAT) and then follow-up with a home sleep test to measure your improvement. The SSA will want all these records, including continuing usage data of your CPAP machine. If you suffer from heart problems, memory issues or mental health issues, you must show proof of a qualifying condition such as pulmonary hypertension and cor pulmonale. And, you need specific tests to support your condition. For instance, the SSA wants to know that your mean arterial pressure is above 40 mmHg on a cardiac catheterization test.
You Need Medical Notes that You’re Unable to Work
Secondly, the SSA wants to know if your Sleep Apnea is severe enough to prevent you from working. Sleep Apnea patients struggle with daytime sleepiness that impairs work. For truck drivers and operators of heavy equipment, Sleep Apnea is not only a work hazard, but life threatening. The SSA requires notes and recommendations from your medical record that may read, “Excessive daytime sleepiness and fatigue.” Or, “The patient should not lift objects over 50 lbs or drive long distances.”
The SSA will also conduct a Residual Functional Capacity Assessment (RFC) to review how fatigue affects your work performance. If you can’t perform your current job, the SSA may recommend less physically demanding work, like a “desk job”, taking your age, job history, and education into consideration. After a lengthy investigation you may be awarded benefits.
You Must Meet Specific Medical Criteria
Meeting the eligibility standards requires very specific criteria. The SSA is more likely to approve benefits for Sleep Apnea symptoms that lead to breathing disorders, heart problems, and mental issues. These sections of the SSA disability evaluation are very specific and must be well documented with doctors’ notes and medical tests:
3.09 Chronic pulmonary hypertension: A cardiac catheterization shows that your mean pulmonary artery pressure is equal to or greater than 40 mm Hg.
4.02 Chronic heart failure/cor pulmonale (right-sided heart failure): Symptoms of pulmonary congestion; systemic congestion; limited cardiac output with abnormal findings on medical imaging.
12.02 Severe cognitive deficits, mood disturbances, or behavioral issues: Neurocognitive disorders that affect memory; judgment; planning; interacting socially; using language.
The Long Road to Disability Benefits
BlueSleep provides care, not legal advice. Applying for disability benefits may require professional help. Legal experts such as Quickaid can help guide you through the process. Here’s a brief synopsis:
Step 1: Non-Medical Criteria
To be eligible for benefits the SSA says you can’t be making more than $1,090 in gross monthly income. This is called the Substantial Gainful Activity (SGA) rule.
Step 2: Severe Impairment
The SSA wants to know if your Sleep Apnea is severe. You’ll have to show proof of a Sleep Apnea Test; complete Daily Living and Vocational questionnaires; and the adjudicator may schedule a Consultative Examination (CE) with a doctor of their choice to perform an exam.
Step 3: Medical Listings
The SSA determines if your Sleep Apnea meets their requirements of a medical Listing of Impairments. As discussed above, you must have medical records from a doctor that you suffer from a respiratory impairment like Cor Pulmonale or Chronic Pulmonary Vascular Hypertension; heart problems; and/or mental disorders.
Step 4: Past Work
The SSA identifies if you can perform work you’ve previously done. The adjudicator determines your Residual Functional Capacity (RFC) taking into account your medical conditions, including Sleep Apnea. They evaluate your ability to communicate, understand, and remember information. They will list your work in the past 15 years preceding the Alleged Onset Date (AOD) of your disability and classify each job by exertion and skill level. In short, if you can still perform any of these jobs, you will be denied benefits, but you have the opportunity to appeal.
Step 5: Other Work
The adjudicator then determines if there is another type of work that you may perform. The SSA will review your education level, age, and work experience and evaluate if you can transfer any skills and abilities from your past work to a new job. In summary, if you’re older; less educated and have few transferable skills, you are more likely deemed Disabled and qualify for benefits.
If the SSA determines you’re severely impaired and can’t hold a job, you’ll be awarded benefits or a Medical-Vocational Allowance. Payments range on average between roughly $1,000-$2,000 a month with a maximum of $3,627 plus 12 months back pay if you qualify.
FAQs
A second visit is scheduled to review the results of your sleep test and discuss treatment options. If you choose treatment with an oral appliance, you can either go to one of our facilities for a digital scan of your teeth or we’ll ship a home impression (mold) kit. If you choose treatment with CPAP, we’ll arrange for a CPAP company to deliver the equipment to your home. Insurance usually covers this treatment, and the CPAP provider will verify coverage for you. Once you’ve received the CPAP, you’ll make an appointment with our sleep specialist to review the use and efficacy of the treatment.
Insurance coverage for oral appliance treatment requires a diagnosis of sleep apnea and symptoms other than just snoring. Our Billing Team gets a pre-authorization for in-network coverage of the treatment and communicates with you regarding any financial responsibility, which may include copays, coinsurance, and deductibles, prior to ordering the appliance. We’ll then ship or email the impressions to the dental lab or manufacturer to make your appliance. Blue Cross and Medicare limit the types of appliances they will pay for. If you want a different type of appliance, not covered by Blue Cross or Medicare, this becomes a self-pay service.
We’ve made thousands of oral appliances for our patients, and we work with many manufacturers and dental labs including: Panthera, Prosomnus, Glidewell, Whole You, Somnomed, Dynaflex, Oventus, and others. We’ll ship the appliance to your home and schedule a virtual fitting session with our staff to instruct you on its use and care. If you require in person adjustments, we’ll schedule a visit in one of our facilities. The time it takes for you to receive your oral appliance depends on how quickly your insurance provides a pre-authorization, and how quickly the lab manufactures the appliance. The process can take as little as 2 weeks, and as long as 3 months or more for some payers.
We’ll ship a home sleep test usually 4 to 8 weeks after you’ve started using the appliance and have adjusted it according to the quality of your sleep. We suggest using the "Snore Lab" app on your smartphone, in addition to observations from your bed partner, and your overall daytime function and energy levels; to help you titrate (adjust) your appliance. Virtual or in person visits are scheduled every 6-12 months thereafter to assure proper efficacy of the treatment, and proper fit of the appliance.
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