Recently questions have arisen about reimbursement for custom fabricated oral appliances coded as E0486 (ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE OR NON-ADJUSTABLE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT). Only oral appliances used for the treatment of obstructive sleep apnea (OAOSA) that meet the durable medical equipment (DME) statutory benefit category requirements are eligible for Medicare reimbursement by the Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
All requirements of the definition must be met before an item can be considered to be DME (CMS IOM 100-2, Ch. 15, §100). Oral devices that do not meet the DME benefit criteria are classified as dental appliances and are not eligible for reimbursement under the DME benefit by the DME MACs.
Since the OAOSA Local Coverage Determination first became effective in January 2011, numerous devices have been submitted to the Pricing, Data Analysis and Coding (PDAC) contractor for inclusion into HCPCS code E0486. Many of these items vary significantly from the characteristics of the predicate product upon which the initial benefit category determination and subsequent HCPCS code were developed. The coding guidelines for OAOSA contained in the Oral Appliances for Obstructive Sleep Apnea Local Coverage Determination related Policy Article describe the requirements that must be met for an OAOSA to be classified as DME and coded as E0486. Based on the wide variety of products that have been submitted for review, the DME MACs are revising the coding guidelines to provide more detailed and specific information to assist with product classification.
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