101 Wilson Rd, Ste D, Monterey, CA 93940, USA
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Patient's Name:
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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 G47.30Temporomandibular Joint Dysfunction / Orofacial PainOther
Patient's Diagnostic Sleep Study Results (without CPAP or OA):
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Statement of Medical Necessity
I am referring the above patient to Dr. Srujal H Shah, DDS INC because I believe it is Medically Necessary for him/her to be fitted for a custom fitted oral appliance, E0486.
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