Insurance Coverage for Oral Appliance
(orthotic) Treatment

MEDICARE:

Medicare will pay only contracted providers; there is no Gap Exception available. Medicare has two separate contracted groups: physicians and durable medical equipment (DME) providers. DME providers actually sell medical goods, such as CPAP machines, wheelchairs and nebulizers. Dentists can sign a medical contract, but they do not qualify for a DME contract. This means that dentists cannot even bill Medicare for an oral appliance (orthotic) used to treat obstructive sleep apnea.

1. Medicare has a different definition of obstructive sleep apnea and it is more stringent than commercial insurance companies.
2. Medicare has only two legal codes for oral orthotic for sleep apnea coverage. These are E0485 (non-custom fabricated) and E0486 (custom fabricated). The E0486 refers to appliances that can be made only by a dentist.

Use of any other code in an attempt to get Medicare to pay for the oral appliance is Insurance Fraud!

Medicare has assigned a “$0.00” fee to the two legal codes. That means that there is no reimbursement for the code E0486. Medicare WILL NOT PAY for oral appliance therapy. At the time of this update (Aug, 2006) Medicare will pay for CPAP therapy, but considers oral appliance therapy to be a ‘convenience item’ for those who simply do not want to use CPAP.

Medicare Supplemental Insurers (e.g. MEDEX) will only pay a portion of the fee if Medicare pays the bulk of the fee. If Medicare maintains a “$0.00” fee for oral appliances to treat obstructive sleep apnea, the supplemental insurers will also pay nothing.

1. Secondary insurers (Not Supplemental) may cover the cost of oral appliance (orthotic) treatment at the same fees they allow for their primary subscribers. Secondary insurers are part of employee benefit plans or part of a retirement benefit package from a previous employer. Prior to receiving services, the dentist must contact the secondary insurer and request coverage of an oral appliance. A letter granting or denying coverage will be sent to the provider and to the patient. A denial can be appealed by the subscriber. Secondary Insurers will not pay for the oral appliance until they receive a form from Medicare stating Medicare will not pay.
2. To obtain a refusal of payment from Medicare, a form 0938-0008 (also known as a HCFA-1490S) must be obtained by the patient, fully filled out and signed. Attached to the form must be a very descriptive bill from the providing dentist that gives the fee paid, the correct Medicare billing code and the appliance (orthotic) used. Having the 510 K # (see list of appliances under Oral Appliance therapy on the drop down menu above) for the specific appliance may be beneficial
3. Keep a copy of all papers sent to Medicare. The first submission is often lost .

PATIENT´S REQUEST FOR MEDICAL PAYMENT

Medical Insurance Benefits Under Social Security Act

http://www.cms.hhs.gov/cmsforms/downloads/cms1490s-english.pdf

The filled out 1490s form and attachments must be sent to the correct regional center covering the area in which the patient lives. Two examples are:

DEMRC Jurisdiction A (All of New England and most of the northeastern area of the US)

NHIC DME Specialty Claim
P.O. Box 9165
Hingham, MA 02043-9165

DEMRC Jurisdiction B (Much of the Midwest)

Administrator DME Non-Assigned
P.O. Box 7031
Indianapolis, IN 46207-7031

Medicare should send the patient a “$0.00” payment slip. This will need to be submitted to the secondary insurer along with all of the medical records. Your provider’s office may be willing to help you put together this packet after the Medicare form is received.

Tricare: Dependents of the US Armed Forces:

1. Will not pay anyone who is not a contracted provider.
2. Requires the referring physician to obtain all of the appropriate referrals.
3. Has minimal coverage for oral appliances (orthotics).

(Note: Members of the Armed Forces and the National Guard who are diagnosed with obstructive sleep apnea and treated with CPAP are considered “non-deployable” and may be released from the service. Oral appliances (orthotics) and surgery may be the therapy of choice.)

Welfare / State Assistance:

I know of no dental provider who accepts this form of payment and is a Diplomate of the Board of Dental Sleep Medicine. I would suggest that patients with this form of medical coverage assume all care is out-of-pocket. Some patients have worked with their social workers and been reimbursed in part or wholly by State Aid.

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

AVALABLE OFFICE HOURS:

9:00 t o 5:00 (Mon)
9:00 to 5:00 (Wed–Sat)
12:00 to5:00 (Sun)
CALL 617.964.4028
in Massachusetts
317.842.9866
in Indiana

 

The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/