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Obstructive sleep apnea (OSA) is effectively treated with continuous positive airway pressure (CPAP). However, many people are not able to become adherent in the initial 90-day trial window for this therapy. Medicare requires a polysomnography and repeat trial documenting adherence before continuing payment for these services. Oral appliance therapy (OAT) is also an OSA first-line therapy but is less effective than CPAP. Methods We created a decision tree to model 4 strategies over a 5-year time horizon: (1) current policy, (2) direct referral for CPAP equipment, (3) OAT followed by CPAP under current policy, and (4) OAT followed by direct CPAP referral in a the Medicare population with mild-moderate OSA and nonadherence to a first attempt at CPAP therapy. Medicare fee schedules in 2020 defined costs. Incremental cost-effectiveness (ICER) was used to identify the supreme strategy Results The current policy was the most expensive. Both the current policy and direct DME referral were dominated by starting with OAT. OAT followed by titration was the most cost-effective strategy with an ICER of $42,586.47. The ICER was sensitive to adherence in the direct CPAP strategy and probability of getting CPAP equipment (vs. lost to follow-up). Conclusion Starting with OAT therapy in those that were CPAP nonadherent on first attempt is cost-effective. Despite decreased effectiveness, the increase adherence to OAT make it an attractive option for retrial of OSA therapy. If OAT therapy fails, the current policy is more cost-effective than direct CPAP referral. Support (if any) This study was supported Career Development Award IK2CX001882 from the United States (U.S.) Department of Veterans Affairs Clinical Sciences Research and Development Service. The contents of this work do not represent the views of the Department of Veterans Affairs or the United States government.

453 Cost-Effectiveness of Requalifying for Positive Airway Pressure Treatment After Initial Nonadherence