Hi talk2us@finetunegums.com!

Great question and the great news is, Medicare does cover E0486!

Since it is DME, it is actually a HCPCS code instead of a CPT code.

Here is a direct link to the Medicare LCD for coverage of oral appliances for sleep apnea. This shows codes, coverage criteria, etc:
https://www.noridianmedicare.com/dme/coverage/docs/lcds/current/oral_appliances.htm

A few main things with billing Medicare for oral appliances:

- your facility must be enrolled as a Medicare DME supplier. There is an application process associated with it! Here is a link to out study group that goes over the application process if you're interested!
http://www.screencast.com/users/DentalWriterStarter/folders/Study%20Group%20Recorded%20Session/media/dbb50445-1416-4840-ae02-a08825c657b3

- Medicare has not included the allowed amounts for E0486 in their fee schedules yet (which is why it appears they don't cover it! Also - E0486 is covered by Medicare DME, so you will not find it on the Medicare Part B fee schedule for your region), even though have paid for them for several years! Jurisdiction D has release it's fees for 2010-2012, but we have seen nothing yet beyond it! Here is a link to that bulletin:
https://www.noridianmedicare.com/dme/news/docs/2012/06_jun/e0486_fee_schedule_amount.html

- When billing to Medicare once you are enrolled as a DME supplier, you will use the modifier NU like you do with your private payers, but will also use KX for Medicare if all required documentation is met.

Hope this helps! Let me know if you have any further questions!

Edited by user Friday, November 7, 2014 10:45:57 AM(UTC)  | Reason: Not specified

Hi guest!

Great question. Basically, in order for a dentist to be able to bill claims to Medicare, they must be enrolled as a DME supplier.

Once they are a DME supplier, there is a certain set of oral appliances for Obstructive Sleep apnea that they can choose from in order to satisfy Medicare guidelines. This is the "PDAC" cleared list of appliances for the code E0486 (which represents the custom made oral appliance to treat OSA)

As far as the cost for services - it will depend on the dentist you choose. If they are a participating DME supplier with Medicare DME, then you will either: pay nothing out of pocket (if you have a supplemental policy), or the usual 20% of services if you do not have a supplemental medical policy (depending on what state you're in, it is usually approx $200-370)

If the dentist you choose is a non-participating DME supplier, they can choose to charge additional on top of the Medicare allowed amount, so you will want to check with them what you out of pocket cost would be, with and without supplemental insurance.

Keep in mind, the information outlined above is for initial treatment through 90 days of follow up care. There is also suggested follow up care (at least annual) after that 90 days, and until Medicare will reimbursement for a new oral appliance (5 years).

Hope this helps, please let me know if you have any further questions!

Hi guest!

No problem. It depends on where you are located :) What state are you in?

Hi guest!

The allowed amount for Medicare DME for E0486 for Ohio is currently approx. in the $1250-1320 range. Your allowed amount is 5% less if you are a non-participating DME supplier than if you are a participating DME supplier.

Hope this helps! Have a great day.

Hi guest!

Medicare DME allows approx. $1000-1060 for E0486 in colorado. (more towards $1060 if you are a participating DME supplier, closer to $1000 if you are a non-participating DME supplier).

Medicare will always pay 80% of the allowed amount.
The patient (or secondary insurer if they have one) will be responsible for the other 20%.

Hope this helps, have a great day!

Hi Guest!

Medicare DME allows approx. $1300 for E0486 in Northern California.

Medicare will always pay 80% of the allowed amount.
The patient(or secondary insurer if they have one) will be responsible for the other 20%.

Medicare does not have a posted fee schedule.

Hope this helps, have a great day!

Hi Guest!

Medicare reimbursement for Jurisdiction C is approximately $1020.

Has the patient met their deductible for the year?

It was because modifier "NU" needed to be used. Hopefully this helps others if anyone else ever runs in to something like this. That raised the allowable to 2,014.81. It was hard to get the insurance rep to help, but I eventually talked her into it.

Edited by user Tuesday, October 4, 2016 12:28:53 PM(UTC)  | Reason: additional info

What's the reimbursement for Kentucky?

Thank you for your quick response!