Custom Oral Appliance Reimbursement

Policy No: 102
Date of Origin: 06/01/2020
Section: Administrative
Last Reviewed: 08/01/2024
Last Revised: 08/01/2023
Approved: 08/08/2024
Effective: 09/01/2024
Policy applies to: Group and Individual & Medicare Advantage

This policy applies only to physicians and other qualified healthcare professionals.

Healthcare Common Procedure Coding System (HCPCS) E0486 – Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment

Custom oral appliances (E0486) are eligible for reimbursement only when provided and billed by a licensed dentist (DDS, DMD) with a valid and current order from the treating physician. Medical records may be requested for review at any time.

All care, including fitting, adjustments, modifications and associated professional services required the day of provision or during the first 90 days after provision of the oral appliance are included in the payment for device. Claims for these will be denied as not separately payable.

Custom oral appliances are eligible for replacement at the end of the 5-year reasonable useful lifetime.

Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33611

Centers for Medicare & Medicaid Services (CMS) Article, A52512, Oral Appliances for Obstructive Sleep Apnea

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