Does Medicare pay for oral devices for sleep apnea?
Oct 01, 2015 · A custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered if criteria A - D are met. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea testing.
Does insurance cover mandibular advancement devices (MAD)?
Mar 07, 2019 · Mandibular advancement devices (MADs) are classified as “same or similar” therapy as CPAP. In the spring of 2018, a Centers for Medicare and Medicaid Services (CMS) contractors system update resulted in the denial of oral appliance therapy as “same and similar” if CPAP had been rented for more than a 90-day period within the past 5 years.
Will Medicare pay for an oral appliance?
Oct 01, 2015 · Article Text. 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 …
What are oral appliances for sleep apnea treatment?
However, Medicare PDAC has a set of criteria the appliance must meet to be PDAC approved for E0486. The related policy article states: Code E0486 may only be used for custom fabricated mandibular advancement devices. To be coded as E0486, custom fabricated mandibular advancement devices must meet all of the criteria below:
Is mouthguard covered by Medicare?
Does Medicare cover snoring devices?
What is an EMA Dental appliance?
What is the average cost of an oral appliance for sleep apnea?
Mouthpieces and other oral appliances can help treat mild to moderate sleep apnea and snoring. The average cost for a sleep apnea mouth guard ranges from $1,800 to $2,000. This includes the appliance, dental visits, and follow-ups. Many health insurance companies will cover the expense.Jun 15, 2021
Does Medicare pay for sleep apnea appliance?
How does a mandibular advancement device work?
How do you deliver an EMA appliance?
Remove upper and lower appliance. Wet two ema elastic straps of the same color and length, then attach each to the lower appliance, rotating the strap on the button hook to seat. The ema logo on the strap should be facing the appliance.
How much does an EMA device cost?
What is the difference between SnoreRx and SnoreRx plus?
What is Maxillomandibular advancement surgery?
Does Tricare cover oral appliance for sleep apnea?
Tricare does cover oral appliance therapy, but only when the patient is seen by a contracted provider. In order to be covered, the patient must have a referral form from their primary care physician.Jan 16, 2017
How much is a snore guard?
How long do you have to pay for oral appliance management?
In other words, patients must pay out of pocket for oral appliance management appointments that occur 90 days or more after the device was delivered. Without benefits provided under Part B, many patients forgo these reevaluation appointments. If a patient eliminates reevaluations due to financial pressures, complications secondary to MAD therapy and sleep-disordered breathing are more likely.
What has caused an increase in billing audits related to E/M codes?
Enforcement changes at the Centers for Medicare and Medicaid Services have caused an increase in billing audits related to E/M codes. Below are answers to commonly asked E/M questions.
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.
Is OAT a dental device?
No. OSA is a medical condition, and OAT is a medical device and reimbursable as DME. However, if adjustments are required after 90 days, the OA is considered a dental therapy. Follow-up care is also considered dental, and dental therapies are not reimbursed by Medicare Part B Services. For more information see Services Excluded under Part B. Note: Although OSA is a non-dental condition, the exception does not apply to OAT.
Does Medicare cover dental exams?
As a matter of routine, Medicare does not cover general dental services or exams under Medicare Part B. The only Part B dental benefits involve surgery, tumors, cysts, etc. When an author (Palmer) asked different Medicare representatives about E & M coverage for oral appliance therapy intake evaluations, she received conflicting responses. DME medical directors said E & M appointments are included in the universal payment for the appliance (not to be billed under Part B). But when she asked a Part B customer service representative, she was advised if a dentist has Part B billing privileges, the services would be covered. What’s more, conflicting information was given by two Part B medical directors confirming the E & M codes should not be covered. We have written numerous letters to the respective medical directors attempting to explain the unfairness of this position to no avail.
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.
Is OAT a DME?
In a January 2019 member newsletter (available with login credentials at www.aadsm.org/email_newsletter_archives.php; see sidebar for full text) the American Academy of Dental Sleep Medicine (AADSM) stated, “Enforcement changes at the Centers for Medicare and Medicaid Services have caused an increase in billing audits related to E/M codes…. OAT is a medical device and reimbursable as DME. However, if adjustments are required after 90 days, the OA is considered a dental therapy. Follow-up care is also considered dental, and dental therapies are not reimbursed by Medicare Part B Services.”
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.
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:
Is E0486 a custom made appliance?
Most custom made oral appliances on the market today meet this definition, of course. However, Medicare PDAC has a set of criteria the appliance must meet to be PDAC approved for E0486. The related policy article states:
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!
What Are Oral Appliances for Sleep Apnea?
Oral appliances are devices put in the mouth to help keep a person’s airway open as they sleep. Two oral appliances are generally used for adults with OSA, and a third is available for children with OSA. People are usually prescribed oral appliances by their sleep specialist, but sometimes they are handled by an orthodontist or dentist.
How Does Oral Appliance Therapy Work to Treat Sleep Apnea?
Oral appliance therapy treats sleep apnea by helping remove physical blockages from the upper airway. Mandibular advancement devices (MADs) help clear the airway by moving the jaw forward, while tongue-stabilizing devices (TSDs) help clear the airway by moving the tongue forward.
How Does Oral Appliance Therapy Compare to Other Treatment Options for Sleep Apnea?
Research shows oral appliance therapies 11 generally do not treat obstructive sleep apnea (OSA) as well as continuous positive airway pressure (CPAP) therapy 12. CPAP therapy performs better than both mandibular advancement devices and tongue-retaining devices 13 when it comes to treating OSA.
Who Are Oral Appliances for Sleep Apnea Best For?
Experts suggest oral appliances for sleep apnea as a treatment for adults who cannot tolerate CPAP therapy 17, and those who snore but do not have OSA.
What Are the Risks of Oral Appliance Therapy for Sleep Apnea?
Using oral appliances to treat obstructive sleep apnea comes with little risk of harm. People who use oral appliances might experience some adverse effects, like discomfort or pain, dry mouth, excessive saliva, or adjustments in tooth placement.
Talking to Your Doctor About Oral Appliances for Sleep Apnea
Oral appliances might be a good option for you if you have been diagnosed with obstructive sleep apnea and have trouble using a CPAP machine. Instead of setting your CPAP aside and going untreated, talk to your doctor about the possibility of trying oral appliances, like a mandibular advancement device or tongue-retaining device.
What is the most common question asked by health insurance companies?
One of the most common questions in the health insurance world is, “Is this covered.”
Does insurance cover sleep apnea?
In many cases, health insurance will cover all or part of the costs of getting an oral appliance for sleep apnea treatment.
Does insurance cover MAD?
Insurance coverage for mandibular advancement devices (MAD) and other oral appliances may differ from that of CPAP machines. Some insurers may cover the full cost, while others may cover part of the cost. Some insurers might not cover any of the cost.
Where to download AASM draft policy?
Download the full draft policy at https://www.aasm.org/resources/pdf/oaosadraft.pdf. The download includes information on submitting a comment.
What board is sleep medicine certified by?
Current subspecialty certification in Sleep Medicine by a member board of the American Board of Medical Specialties (ABMS);
Can a device measure AHI?
This determination will be made on a device-by-device basis. Currently there is no device that indirectly measures AHI or RDI that meets this criterion.
Does Medicare cover oral appliances?
The DME contractors on September 18 issued a draft policy regarding application of Medicare coverage for oral appliances prescribed for patients with obstructive sleep apnea (OSA).
Does Medicare cover sleep tests?
The patient has a Medicare covered sleep test ; The patient is not able to tolerate a positive airway pressure device, or the treating physician determines that the use of a PAP device is contraindicated; and. The device is provided by a licensed dentist.
Can a DME perform HST?
Prior to receiving a HST, patients must receive instruction on how to apply the HST device, and this instruction may not be performed by the DME supplier.
How many payments does Medicare pay for CPAP?
As far as a CPAP machine, when a person is prescribed a machine, Medicare contracts with the DME and pays for it in 12 payments. After the 12th payment and the machine is paid for, the individual keeps/owns the machine. Just wanted to make a clarification.
How long does Medicare pay for CPAP?
If you have received a CPAP machine , covered by Medicare, and find yourself unable to tolerate it, Medicare will not pay for an oral appliance until 5 years has passed. The reverse is also true. This means you have to think about costs involved.
How many Herbst appliances are there?
CMS has very stringent rules for oral appliances. At present there are 22 appliances that are contracted with the Price coding analysis segment of the government (PDAC). 14 of these appliances are various forms of Herbst appliances, but are all made by different laboratories often designed to get a piece of the Medicare pie. Some are cast metal and very thin, some have bulky proprietary hardware. Those that are not Herbst or TAP devices are the Medley Gold, OASYS with lingual lifters or nasal dilators and the SnoreHook Splint (similar to a TAP).
What is not a Herbst device?
Those that are not Herbst or TAP devices are the Medley Gold, OASYS with lingual lifters or nasal dilators and the SnoreHook Splint (similar to a TAP). Be aware that Medicare has recently gone through a system wide update and will only pay to treat your sleep apnea once every 5 years.
Why is oral appliance literature problematic?
Oral appliance literature is always problematic because there are such small numbers of patients. One study about the new diagnosis of high blood pressure, in those with sleep apnea, lumedp moderate sleep apneics with mild sleep apneics but Marin, JAMA 2012 (1886 subjects) showed that the incidence of high blood pressure in those ...
What is the standard accepted definition of success with a treatment for sleep apnea?
Reducing AHI to below 5 and resolution of symptoms is the standard accepted definition of success with a treatment for sleep apnea. Many authors use a looser definition of success, as do ENT surgeons, of decreasing the AHI by 50% and bringing the final AHI <20 because it makes their treatment look better.
Is CPAP based on monthly rental?
An oral appliance is custom made and has to be bought outright. CPAP is based on monthly rental and, therefore, may be more affordable out-of-pocket. Discuss the options of therapy with your sleep physician and the costs involved.