Oral Appliances for Obstructive Sleep Apnea - Policy Article

Revision Effective Date: 08/08/2021
CODING GUIDELINES:
Removed: Coding and billing information pertaining to multifunction ventilators coded E0467
CODING VERIFICATION REVIEW:
Removed: Direction for HCPCS Code E0467 from section


05/16/2024: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/08/2021
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/08/2021
CODING GUIDELINES:
Moved: E0486 code verification review (CVR) language to coding verification review section
Revised: Coding instructions for multifunction ventilators (E0467) (Effective 01/01/2019)
CODING VERIFICATION REVIEW:
Added: Section header and PDAC CVR information
Added: CVR requirement for products coded E0486 and E0467


11/11/2021: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/08/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Language regarding no aspect of a home sleep test may be performed by a DME supplier
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “face-to-face” to “in-person”
Revised: History elements of the treating practitioners evaluation by separating the “sleep hygiene inventory” from the “duration of symptoms” bullet
MODIFIERS:
Revised: The reference to the coverage criteria within the “Coverage Indications, Limitations, and/or Medical Necessity” section of the LCD
CODING GUIDELINES:
Revised: Coding Verification Review statement for E0486 by removing “appropriate” prior to “Product Classification List”
Added: Incorrect coding denial statement for HCPCS codes that do not receive written coding verification review
Removed: Language related to the use of HCPCS code A9270 when coding verification was not received
06/24/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date:
 04/03/2020
CODING GUIDELINES:
Revised: Guidance for billing HCPCS code E0467 based on DOS


07/16/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
 Added: Section and related information based on Final Rule 1713
 POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
 Revised: “Physicians” to “Treating practitioners”
 ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
 Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
 ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
 Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


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/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
 CODING GUIDELINES:
 Added: E0467 Coding Guidelines
Revised: Language for custom fabricated oral appliance (E0486)
 ICD-10 CODES THAT ARE COVERED:
 Added: Diagnosis code formerly listed in the LCD
 ICD-10 CODES THAT ARE NOT COVERED:
 Added: Notation excluding all unlisted diagnosis codes from coverage


04/04/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Face to Face clinical evaluation, Modifier requirements
CODING GUIDELINES:
Revised: Examples of articulations that do not meet the requirement of a fixed hinge.
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 01/01/2015
CODING GUIDELINES:
Revised: Coding Guidelines based on DME MAC article: “Correct Coding for Oral Appliances for the Treatment of Obstructive Sleep Apnea (E0486)” – Effective July, 01, 2012