Oral Appliances for Obstructive Sleep Apnea

Revision Effective Date: 08/08/2021
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: “face-to-face” to “in-person”


Removed: Not reasonable and necessary denial statement regarding custom fabricated mandibular advancement devices that do not receive written coding verification
Revised: Sleep Tests section to point to NCD 240.4.1 and applicable A/B MAC LCDs and Billing and Coding articles
SUMMARY OF EVIDENCE:
Added: Information related to diagnostic sleep testing
ANALYSIS OF EVIDENCE:
Added: Information related to diagnostic sleep testing
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments (A58823)

Revision Effective Date: 01/01/2020
CODING INFORMATION:
Removed: Field titled “Bill Type”
 Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
As required by CR 10901, the ICD-10 information has been moved to all Policy Articles. There is no change in coverage.

Revision Effective Date: 01/01/2020
 COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
 Revised: “physician” to “treating practitioner”
 Removed: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related PA
 Added: Statement to refer to ICD-10 code list in the LCD-related Policy Article
 GENERAL:
 Revised: Order information as a result of Final Rule 1713
 DOCUMENTATION REQUIREMENTS:
 Revised: “physician’s” to “treating practitioner’s”
 GENERAL DOCUMENTATION REQUIREMENTS:
 Revised: “Prescriptions (orders)” to “SWO”


02/13/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713.

Revision Effective Date: 01/01/2019
 COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
 Removed: Statement to refer to diagnosis code section below
 Added: Refer to Covered ICD-10 Codes in the LCD-related Policy Article
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
 Moved: Diagnosis code to the LCD-related Policy Article diagnosis code section per CMS instruction
 ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
 Moved: Statement about noncovered diagnosis codes moved to LCD-related Policy Article noncovered diagnosis code section per CMS instruction

Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Supplier manual reference from Miscellaneous
Removed: PIM reference under Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article

Effective July 1, 2016 oversight for DME MAC LCDs 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 LCDs.

Revision Effective Date: 10/31/2014
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
DOCUMENTATION REQUIREMENTS:
Added: Continued Medical Need/ Continued Use sections
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
Added: Instructions for equipment retained from a prior payer
Added: Repair/Replacement section
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Diagnosis code reference