Medicare changes coverage for sleep apnea appliances

The Durable Medical Equipment Medicare Administrative Contractors has released a new local coverage determination for oral appliances used in the treatment of sleep apnea, according to a story in Sleep Review.

The policy, effective for claims with dates of service on or after January 3, 2011, states that a custom-fabricated mandibular advancement oral appliance used to treat obstructive sleep apnea is covered if certain criteria are met.

Given the growing awareness that many people are not compliant with continuous positive airway pressure (CPAP) therapy, a second treatment option should increase the number of people who are successfully treated for obstructive sleep apnea, Steve Moore, vice president of sales and marketing for Airway Management, said in the story.

According to the policy, a custom-fabricated mandibular advancement oral appliance (E0486) used to treat obstructive sleep apnea (OSA) is covered under the following criteria:

• The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea testing.
• The patient has a Medicare-covered sleep test that meets either of the following criteria:
  1. The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or
  2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
     1. Excessive daytime sleepiness, impaired cognition, mood disorders, or
     2. insomnia; or
     3. Hypertension, ischemic heart disease, or history of stroke.
• If the AHI >30 or the RDI >30 and meets either of the following:
  1. The patient is not able to tolerate a positive airway pressure (PAP) device or
  2. The treating physician determines that the use of a PAP device is contraindicated.
• The device is ordered by the treating physician following review of the report of the sleep test. (The physician who provides the order for the oral appliance could be different from the one who performed the clinical evaluation in the first criterion.)
• The device is provided and billed for by a licensed dentist (DDS or DMD).

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