The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) have issued updated coding guidelines for oral appliances billed for reimbursement under code E0486. Using these requirements, all products currently listed on the coding system must be re-reviewed, according to information from Jurisdiction C.
Since the oral appliance local coverage determination became effective in January 2011, a variety of devices have been submitted to the Pricing, Data Analysis and Coding (PDAC) contractor for inclusion into HCPCS code E0486. Due to the variability of submitted products submitted for coding under E0486, the DME MACs have provided updated information about product classification.
Effective July 1, 2012, oral appliances eligible for reimbursement under HCPCS code E0486 are those that meet the following:
A custom fabricated oral appliance (E0486) is one which is individually and uniquely made for a specific patient. It involves taking an impression of the patient’s teeth and making a positive model of plaster or equivalent material. Basic materials are used with the positive model to produce the final product. Custom fabrication requires more than trimming, bending, or making other modifications to a substantially prefabricated item. A custom fabricated oral appliance may include a prefabricated component (e.g., the joint mechanism).
Code E0486 may only be used for custom fabricated mandibular advancement devices. To be coded as E0486, custom fabricated mandibular advancement devices must meet all of the criteria below:
* Have a fixed mechanical hinge at the sides, front or palate; and,
* Be able to protrude the individual beneficiary’s mandible beyond the front teeth when adjusted to maximum protrusion; and,
* Incorporate a mechanism that allows the mandible to be easily advanced by the beneficiary in increments of one millimeter or less; and,
* Retain the adjustment setting when removed from the mouth; and,
* Maintain the adjusted mouth position during sleep; and,
* Remain fixed in place during sleep so as to prevent dislodging the device; and,
* Require no return dental visits beyond the initial 90-day fitting and adjustment period to perform ongoing modification and adjustments in order to maintain effectiveness.