I am also having trouble with Aetna for E0486. The patient has met her deductible and we also added the modifier NU initially with the claim. What is Oklahoma's medicare allowed amount. Aenta is stating it is $402.96


Thanks

Hi,

What is the reimbursement for Jurisdiction A for DME through Medicare?

Thank you.

Can you tell me what the rate is for E0486 in Jurisdiction D and where I can find documentation of it?

Thanks!

Thank you so much! I appreciate the quick response!

Hi Kev!

Great question. Medicaid for Washington State does not appear to have E0486 listed on their fee schedule either, so I can't say for sure. Although, the clients i have worked with who have billed Medicaid for E0486 reported similar or even sometimes higher allowables for Medicaid than Medicare in their states!

Hi guest!

My responses below in bold:

Hi, I am a patient working with a dental office unfamiliar with billing and pre-certifying insurance for custom devices for sleep apnea and we are receiving conflicting/ confusing information from my insurance company Blue Cross Blue Shield here in Texas. I did receive written approval from BCBS to treat my dentist as an in network provider.

That's great! Make sure you hold onto a copy of that approval in case you need it after the claim is processed ;)

I was told by BCBS to give them the following instuctions when I gave them a copy of the medical policy documentation need for the Medical Policy # MED205.001 that is associated with the appliance code E0486. They need to submit:
1) the completed predetermination form provided by BCBS
2) the medical policy documentation (detailed in the policy document attached) with dentist's information and specialty as well as my information - and an explanation of how the appliance code EO486 will treat the diagnosis code for apnea G47.30 - and the clinical notes etc.

So first off, in case you or the office doesn't yet have it, here is a link to BCBS of Texas's pre-determination request form: https://www.bcbstx.com/provider/pdf/predeterminationform.pdf

And here is the link to BCBS of Texas's current medical policy that you mentioned above titled "Diagnosis and Medical Management of Sleep Related Breathing Disorders":
http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=inej3tjy&corpEntCd=TX1

The policy states the following for criteria for coverage for an oral appliance to treat Obstructive Sleep Apnea (OSA):

"INTRAORAL APPLIANCES

Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult patients with mild to moderate OSA who prefer oral appliances (OA) to CPAP, or who do not respond to CPAP, or are not appropriate candidates for CPAP, that meet all of the following conditions:

1. The device is prescribed by a treating physician, and

2. The device is custom-fitted by qualified dental personnel, and

3. The patient does not have loose teeth or advanced periodontal disease, AND

Either:

• MILD OSA: Apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than or equal to 5 events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, documented hypertension, ischemic heart disease, or history of stroke,

OR

• MODERATE OSA: AHI or RDI greater than or equal to 15 events per hour, but less than or equal to 29 events per hour.

Oral devices to prevent temporomandibular joint (TMJ) disorders are considered experimental, investigational and/or unproven.

NOTE: CPAP has been shown to have greater effectiveness than oral appliances in general. This difference in efficacy is more pronounced for patients with severe OSA, as oral appliances have been shown to be less efficacious in patients with severe OSA than they are in patients with mild-moderate OSA. Therefore, it is particularly important that patients with SEVERE OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance."


So - here's the thing. It's not completely unheard of for a medical insurer to cover a custom made oral appliance with the diagnosis code G47.30.......however, most medical insurers do require the diagnosis code G47.33 in order to cover a custom made oral appliance for OSA (HCPCS code E0486). The reason why? G47.33 specifies "obstructive" sleep apnea, whiel G47.30 represents "unspecified" sleep apnea (and custom made oral appliances have been clinically proven to treat obstructive sleep apnea specifically). Here's the ICD-10 descriptions of both codes below:
G47.33 - Obstructive sleep apnea (adult) (pediatric)
G47.30 - Sleep apnea, unspecified

The reason I am saying all of this - it is a definite possibility the claim will ultimately be denied unless the diagnosis is G47.33....which if a sleep study was performed with an Apnea Hypopnea Index (AHI) of 5+ (meaning you were diagnosed with mild, moderate, or severe obstructive sleep apnea), you should be able to get that diagnosis code on an Rx for the oral appliance from your physician to give to your dentist.

I was told they should wait to receive the authorization before submitting a claim (and that they have 12 months from the date of service to do so) as without all documentation the claim will likely be denied by BCBS.

Yes that is all correct. A pre-authorization/pre-determination, when required, should be approved prior to the health professional rendering services to the patient, and many insurers do allow up to 12 months from the date of service for the health provider to file the claim. Some insurers have a shorter time frame, such as between 3-6 months as well.

Do I need to tell them to include the modifier NU to the billing code E0486?

Yes - modifier "NU" stands for "new equipment" and should always be used when filing for E0486.

Is there anything else they should be doing and is there any way to know if BCBS will reimburse me for this?

It sounds like you are on the right track! You can never get an insurer to "guarantee" they will reimburse for a service because it depends on many factors such as: pre-auth/pre-d being approved, claim being filed correctly, your specific benefits (for example - if the cost of the procedure/service is $3000, and your deductible is $3000 and none has been yet met, they will "cover" the procedure and will apply to your deductible so your deductible will be met for the year, but you will not get a reimbursement check because your deductible has to get paid first). The most important thing to make sure that depending on the severity of your diagnosed OSA, that the criteria for coverage is documented properly and submitted with the pre-auth/pre-d and/or claim


Thanks!

No problem, hope this helps, have a great day!

You're very welcome!

Hi Guest!

Connecticut is part of Medicare DME Jurisdiction A (governed by Noridian), so the allowed amount is appropriately $1750-1800. Medicare will cover 80% of that, and either the patient or a secondary insurance if they have it will generally cover the other 20%.

Hope this helps, have a great day!

Hi Guest!

Arkansas is part of Medicare DME Jurisdiction C (governed by CGS), so the allowed amount for E0486 is appropriately $1050. Medicare will cover 80% of that, and either the patient or a secondary insurance if they have it will generally cover the other 20%.

Please keep in mind you must be enrolled as a Medicare DME supplier in order to bill Medicare for custom fabricated oral appliances for OSA!

Hope this helps, have a great day!

Hi Lorena!

Great questions.

Yes the DME supplier application is different than the 855i enrollment form.....the application to become a Medicare DME supplier is the 855s enrollment form. For dental practices, this is the application to complete if you wish to bill Medicare for custom made oral appliances for Obstructive Sleep Apnea (OSA). Here is a link to it: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855s.pdf

The 855i and 855b enrollment forms are to become a Medicare Part B provider. Here are the links to those:

855i:
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855i.pdf

855b:
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855b.pdf


When enrolling as a Medicare DME supplier for oral appliances for OSA, you don't want to "opt out of being in-network", but rather you have two options when enrolling as a DME supplier:

1) enroll as a participating DME supplier (meaning you bill accept Medicare's allowed amount for E0486 as payment in full and not balance bill anything beyond any applicable deductible & coinsurance)

2) enroll as a non-participating DME supplier (meaning you have the option on a claim by claim basis to either "accept assignment" or "not accept assignment". Accepting assignment means you will not balance bill above Medicare's allowed amount, not accepting assignment meaning you can balance bill up to your usual fee since there is no "limiting charge" for this DME item).

If you wish to enroll as a participating DME supplier, you will complete a 460 enrollment form in addition to the 855s. Here is a link to the 460 form: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms460.pdf

If you wish to enroll as a non-participating DME supplier, do not complete the 460 form.

We do have a great DME application service that assists dental practices to complete the Medicare DME enrollment application, here is a link to more information about it: https://niermanpm.com/dental-medical-billing-services/dme-application

Hope this helps, have a great day!

Edited by user Monday, February 13, 2017 9:45:38 AM(UTC)  | Reason: Not specified