DME contractors have published a draft Local Coverage Determination, outlining coverage policies for oral appliances for patients with OSA.
According to the draft, an oral appliance is covered if it is used to treat OSA and if the following criteria (A-D) are met:
A. The patient has a face-to-face clinical evaluation by the treating physician (MD or DO) prior to the sleep test to assess the patient for obstructive sleep apnea.
B. The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2):
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 insomnia; or (2) Hypertension, ischemic heart disease, or history of stroke.
C. The patient is not able to tolerate a positive airway pressure (PAP) device or the treating physician determines that the use of a PAP device is contraindicated.
D. The device is provided by a licensed dentist (DDS or DMD).
The policy also addresses the use of custom fabricated oral appliances:
A custom fabricated oral appliance is covered only if there is an anatomical abnormality of the mouth, jaw, or throat that cannot be accommodated by a prefabricated appliance. If this criterion is not met but the general coverage criteria (A-D above) are met, payment will be based on the allowance for the least costly medically appropriate alternative.
DME contractors are accepting comments on the draft policy through November 3.
The full draft policy can be downloaded online.
Oral Appliances: Here to Stay