A custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive sleep apnea A sleep disorder where breathing is interrupted.Sleep Apnea
Obstructive sleep apnea
A sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep, and causes unrestful sleep.
Full Answer
Does Medicare cover oral appliance devices for sleep apnea?
Coverage of oral appliance devices for the treatment of OSA will continue to rely on a Medicare-covered diagnostic sleep test with qualifying values (as described in the Coverage Indications, Limitations, and/or Medical Necessity section above) that is eligible for coverage and reimbursement by the A/B MAC contractor.
What is a mandibular advancement device for sleep apnea?
Mandibular Advancement Device. The mandibular (also referred to as the mandible) is a jawbone and the mandibular advancement device aims to advance or move it forward. It is the most widely used device for sleep apnea and looks much like a mouth guard used in sports.
What is the HCPCS code for Mandibular advancement?
Custom fabricated mandibular advancement devices that do not incorporate all of the criteria above must use HCPCS code A9270 (NON-COVERED ITEM OR SERVICE). Do not use HCPCS code E0486. Tongue positioning appliances are coded A9270.
How much does a mandibular advancement device cost?
The majority of off-the-shelf devices range from$75 to $150. Custom devices are the most expensive, ranging from $1500 to $2000. How Long Does a MAD Last? Naturally, the frequency of usage and regular cleaning will have an impact on how long a mandibular advancement device will last.
Are mandibular advancement devices covered by Medicare?
Oral appliances for obstructive sleep apnea receive coverage if you meet specific criteria. The mandibular advancement device is the most popular dental appliance to help treat sleep apnea. This retainer-style medical oral appliance is one of the sleep apnea devices covered by Medicare if the situation qualifies.
Does Medicare pay for sleep apnea appliance?
If you diagnosed with obstructive sleep apnea, Medicare Part B will cover an oral appliance, which is an alternative to a CPAP machine, or Continuous Positive Airway Pressure. Your doctor must prescribe the appliance.
Does Medicare cover ASV machine?
Generally, Medicare covers 80 percent of costs related to sleep apnea machines. The Part B deductible applies.
Does Medicare cover Inspire implant?
Is Inspire covered by Medicare? Medicare is reimbursing the cost of Inspire therapy based on medical necessity across the United States.
How often can you get a new CPAP machine under Medicare?
Medicare will usually cover a new CPAP machine every 5 years! This is also how long most manufacturers estimate that a CPAP machine will last, so even if your machine seems to be working, it's a good idea to replace it before it breaks down.
Is SomnoMed covered by Medicare?
SomnoMed Device Costs: Facts About Insurance Coverage for SomnoDent Oral Devices. Oral appliance therapy is virtually always covered by medical insurance and government payers (Medicare, Medicaid, and military) using the same criteria that are used for coverage of continuous positive airway pressure (CPAP) therapy.
What is the Medicare approved amount for a CPAP machine?
How much does a CPAP machine cost with Medicare? If the average CPAP machine costs $850, and Medicare covers 80 percent of it, then you'll have to pay $170; however, you'll also have to account for the Medicare Part B deductible, which is $203 in 2021, meaning your total cost may be up to $373.
Does ResMed accept Medicare?
Do you accept either Medicare or Medicaid? Medicare and Medicaid will pay for medical equipment and supplies only if a supplier has a Medicare or Medicaid supplier number. Expedite, LLC, the operator of the ResMed Shop, does not have a Medicare or Medicaid supplier number.
Do I own my CPAP machine?
After the rental period is over, you own the device. However, these insurance companies are often requiring proof that you are using the equipment and meeting their usage requirements (at least 4 hours per night for 70% of nights) in order to continue payment.
Who is a candidate for Inspire?
You are eligible for Inspire Sleep Surgery if: You have moderate to severe OSA with a diagnostic sleep study in the past 2 years. You tried CPAP therapy and it didn't work. You do not have significant trouble falling asleep. You have a body mass index (BMI) of 32-35 or less.
How do you get approved for Inspire?
You might be a candidate for Inspire if...You have moderate to severe obstructive sleep apnea.You are unable to use or get consistent benefit from CPAP.You are not significantly obese.You are age 18 or above.
What are the dangers of Inspire?
The most common side effects associated with treatment are tongue abrasion, mouth dryness, and discomfort stemming from the nerve stimulator. In rare cases, some people experience muscle atrophy and partial tongue paralysis. Your doctor can fine-tune your device's settings to help alleviate these side effects.
Document Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Coverage Guidance
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
Does Medicare cover dental appliances?
The most common form of sleep apnea is obstructive sleep apnea, and Medicare does offer coverage for some dental appliances ...
Does Medicare cover sleep apnea?
Medicare also covers some other dental appliances that can help reduce the symptoms of sleep apnea. Many of these are mouthpieces that work to move the jaw into a specific position that opens the airway and promotes better breathing while you sleep.
How much is a surety bond for Medicare?
Medicare has historically required DME suppliers to post a $50,000 surety bond for the privilege of providing medical equipment to Medicare beneficiaries. Its purpose is to ensure any auditor will be guaranteed a payment of at least $50K if a records audit uncovers error (s) in the documentation.
Can a dentist denial a CPAP?
In March 2018, dentists began receiving denials for Medicare beneficiaries who had failed CPAP due to “same and similar” treatment. Without warning, E0601 (CPAP) and/or E0470 (BiPAP) if utilized over 90 days and certified by a physician and E0486 (MAD) are enforced as same or similar therapies. That means a Medicare patient can have only one of these therapies for any 5-year period.
What is the Medicare LCD for oral appliances for OSA?
The Medicare LCD for oral appliances for OSA states the coverage criteria for mild, moderate, and severe OSA as follows:#N#The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 – 3):
Why is it important to bill dental practices for Medicare?
The importance is two-fold; first to ensure that your practice is protected in the event of an audit from Medicare, and second to ensure that your Medicare patients receive the coverage that is available to them.
What modifier is used for OSA?
When a claim is submitted to Medicare DME for an oral appliance for OSA, modifier KX, GA or GZ must also be present or the claim will be rejected. It is important that practices do not simply use the KX modifier on every claim because they know it will be paid.
What is DME in Medicare?
Currently, custom made oral appliances for OSA are categorized as Durable Medical Equipment (DME) under Medicare. DME is a broad range of items that are used by a patient in a home setting to serve a medical purpose, such as wheelchairs, positive airway pressure devices, canes, the list goes on. To bill Medicare for DME items, a practice (or company) must enroll as a DME supplier using the 855s application. While this is not a quick process, it can be well worth it as Medicare is the largest medical insurer in the United States.
How long is follow up care covered by E0486?
Follow up care 90 days from the delivery date are included in the reimbursement. Follow up care for 90 days being included in the reimbursement for E0486 is not a foreign concept, as most medical insurers follow this guideline. However, it is important to know that the related policy article states:
Can a DME perform HST?
This one is simple. The LCD states: No aspect of a HST, including but not limited to delivery and/or pickup of the device, may be performed by a DME supplier. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.
Who is the LCD covered by?
The LCD clearly states as part of the coverage criteria: The device is provided and billed for by a licensed dentist (DDS or DMD). So if you have a physician or lab in your area providing custom made sleep appliances to their Medicare patients – you may want to show them a copy of the LCD!
General Information
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
ICD-10-CM Codes that Support Medical Necessity
The presence of an ICD-10 code listed in this section is not sufficient by itself to assure coverage. Refer to the LCD section on " Coverage Indications, Limitations, and/or Medical Necessity " for other coverage criteria and payment information.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Does dental insurance cover snoring appliances?
Dental appliances for Obstructive Sleep Apnea. Before getting too far ahead, it’s important to understand that in most cases, health insurance companies are not going to cover an appliance that is used for the sole purpose of controlling snor ing.
Is a dental appliance covered by Medicare?
Appliances that are custom made by the dentist for the purpose of controlling obstructive sleep apnea are considered a medical necessity and are often covered by private insurance as well as Medicare, Medicaid, and obamacare when certain conditions are met.