Dental Providers Billing for Sleep Apnea Appliance

For patients who cannot tolerate a continuous positive airway pressure (CPAP) machine, a provider may prescribe an oral appliance. The oral appliance is considered Durable Medical Equipment (DME). Dentists assure the proper fit of the appliance. Most appliances require that a dentist take necessary impressions and a bite registration.

Correct coding for oral appliances for the treatment of obstructive sleep apnea:

• E0485: Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment
• E0486: Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment

For a custom fabricated appliance to be covered, criteria 1 – 4 must be met:

1. There must be a face-to-face evaluation by a provider prior to a sleep test to assess the member for obstructive sleep apnea testing
2. The sleep test must meet one of the following criteria:
   1. The apnea-hypoxia index (AHI) or Respiratory Disturbance Index (RDI) is great 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 the following:
      1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia or
      2. Hypertension, ischemic heart disease, or history of stroke; or
   3. If the AHI is greater than 30 or the RDI is greater than 30 and meets either of the following:
      1. The member is not able to tolerate a positive airway pressure device; or
      2. The treating provider determines that the use of a positive airway pressure device is contraindicated
3. The device must be ordered by a provider following review of the report of the sleep test (the provider who provides the order for the oral appliance could be different from the one who performed the clinical evaluation in criterion 1).
4. The device is provided and billed for by a dentist

A custom fabricated oral appliance (E0486) is one that is individually and uniquely made for a specific member. It involves taking an impression of the member’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 following criteria:

1. Have a fixed mechanical hinge (see below) at the sides, front, or palate
2. Be able to protrude the individual member’s mandible beyond the front teeth when adjusted to maximum protrusion
3. Incorporate a mechanism that allows the mandible to be easily advanced by the member in increments of 1 mm or less
4. Retain the adjustment setting when removed from the mouth
5. Maintain the adjusted mouth position during sleep
6. Remain fixed in place during sleep so as to prevent dislodging the device
7. 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 (see below)

A fixed hinge is defined as a mechanical joint containing an inseparable pivot point. Interlocking flanges, tongue and groove mechanisms, hook and loop or hook and eye clasps, elastic straps or bands, etc. (not all-inclusive) do not meet this requirement.

Items that require repeated adjustments and modification beyond the initial 90-day fitting and adjustment period in order to maintain fit and/or effectiveness are not eligible for classification as DME. These items are considered as dental therapies, which are not eligible for reimbursement.

Required Authorization

1. Submit a Medical Service Authorization Request Form
2. Use the appropriate ICD-10 diagnosis code
3. Indicate the appropriate Healthcare Common Procedure Coding System (HCPCS) code (E0485 or E0486) for the appliance

The supporting documentation must include the following:

1. A copy of the sleep study results and interpretation by a physician
2. Documentation of a trial of a CPAP machine

Billing and Documentation

Use the Professional 837P claim.

Other requirements:

1. Complete and fax the Claim Attachment Cover Sheet
2. Include the following with the cover sheet:
   1. Copy of the lab slip with fee included
   2. Cost of materials including those used to fabricate the impression and bite registration

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Updated_11/01/2018