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Medicare Approved Oral Appliances

Medicare Approved Oral Appliances for OSA 

We accept and bill medicare for the treatment of Obstructive sleep apnea

As of July 2012, Medicare only accepts the Herbst oral appliance for the treatment of OSA

See the new law and information below:

 

 

Revised DME Medicare Coding Guidelines for Oral Appliances - July 2012

In an article published July 5, 2012, CGS Administrators LLC announced that the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have revised the coding guidelines for custom fabricated oral appliances coded as E0486. These guidelines are used by the Pricing, Data Analysis and Coding (PDAC) contractor when a device manufacturer submits a coding verification application for inclusion into code E0486 of Medicare’s Healthcare Common Procedure Coding System (HCPCS).

In the article, “Correct Coding for Oral Appliances for the Treatment of Obstructive Sleep Apnea (E0486),” CGS noted that a “wide variety of products” have been submitted to PDAC for review since the policy was implemented in January 2011, and numerous questions have arisen about Medicare reimbursement for oral appliances used for the treatment of obstructive sleep apnea (OAOSA). The coding guidelines were revised with the stated purpose of providing “more detailed and specific information to assist with product classification.”

The Revised Guidelines

  • Provide much more detail about the “fixed hinge” that is a required part of the device
  • Retain the requirement that the device allow the mandible “to be easily advanced by the beneficiary in increments of one millimeter or less”
  • Add new criteria for maintaining the adjusted mouth position and remaining fixed in place during sleep
  • Add the criterion that the device must “require no return dental visits beyond the initial 90-day fitting and adjustment period to perform ongoing modification and adjustments in order to maintain effectiveness”

Effective July 1, 2012, all product submissions will be reviewed by PDAC using these revised coding guidelines, and devices currently listed by PDAC will be re-reviewed accordingly. Effective November 1, 2012, only those products that have been re-reviewed through the PDAC coding verification review process and listed as code E0486 on the PDAC Durable Medical Equipment Coding System (DMECS) website may use this code.

CGS noted that coding decisions are updated frequently. Therefore, suppliers should refer to the Product Classification List often to ensure that items billed have been coded by the PDAC. The AADSM also maintains a list of devices that have been coded by PDAC as E0486 on the AADSM website at http://www.aadsm.org/managementresources.aspx.

 

As of December 26,2012, To date, PDAC has verified that these devices meet the new guidelines and are eligible for Medicare reimbursement:

  • Herbst by Dynaflex
  • Herbst by Gergen's Orthodontic Lab
  • TAP by Airway Management
  • TAP 3 Elite by Airway Management 
  • Telescopic Herbst by Great Lakes Orthodontics
  • SUAD by Strong Dental LTD
  • SUAD Elite by Strong Dental LTD
  • UCLA Modified Herbst by Space Maintainers Laboratory

 

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