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Since E0486 in still not on the Medicare fee list, what have you recently been seeing for reimbursement or "allowed" in Georgia?
Thanks in advance.
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Hi Guest!
Yes we have been getting reports of a few insurers trying to deny claims for E0486 stating the reason being that E0486 currently shows as $0 on Medicare DME's fee schedule, which is true even though Medicare has officially paid for this code since 2010. So typically, the best response in this situation is to appeal & provide the insurer with a copy of a recent as possible EOB from Medicare DME showing the current allowed amount for E0486.
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Thank you very much! The insurance is Anthem, commercial policy. He paid $1792.00. Sadly, he has been told he would need a different code since there is no pricing with that code.
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Hi Guest!
If the appliance is a custom made intra-oral appliance to treat Obstructive Sleep Apnea, then E0486 with modifier NU is the correct code to use. Although some medical insurers do not have a set amount for it on their fee schedule, this code is reimbursed by Medicare and most (if not all) private payers as well. Depending on your region, we typically see the fee at approx $2500-4000, and depending on the region and the payer we typically see the allowed amount approx $1800-2400.
Hope this helps!
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Hi there! I am trying to help a member file a claim for E0486 with his medical insurance, however the insurance does not have pricing for this code. Is there another CPT code that could possibly be used that we could try?
Thanks in advance!
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Message was deleted by a Moderator. | Reason: Not specified
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Hi Guest! Great question. Yes, the dental practice would use HCPCS code E0486 for the appliance (includes 90 days of follow up/adjustment typically as well) on the CMS1500 medical claim. While there are those new codes in the CDT coding system, dental insurers don't offer coverage for custom made oral appliance to treat Obstructive Sleep Apnea (OSA), as it is considered a medical expense. Also keep in mind, you'll need a copy of the patient's sleep study (to provide the diagnosis of OSA - some insurers require this study to be performed within the last year), as well as a prescription from a physician for the sleep appliance. There are also a few other criteria a patient may need to meet, depending on the severity of their OSA and their insurer's coverage criteria. Here is a link to our blog with additional information about billing sleep appliances to medical: https://niermanpm.com/blog/what-you-need-to-get-custom-oral-sleep-appliances-paid-by-medical-insurance/Hope this helps!
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Hi, We are dental office and want to start billing for Sleep Apnea Appliances, but not too familiar with this... Does the dental provider use E0486 and bill on a 1500 claim? I understand there are new Dental codes, D9947. Do we use the new dental code or continue using E0486? I appreciate your help!
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2022 NEW Dental Codes for Sleep Apnea Appliance therapy
D9947 — Custom sleep appliance fabrication and placement (documentation purposes)
D9948 — Adjustment of custom sleep apnea appliance
D9949 — Repair of custom sleep appliance
These new codes went into effect in January, 2022. It is recommended to continue to bill sleep apnea appliances to medical insurance with code E0486 NU. No dental policies have indicated that oral appliances will be covered under dental insurance. so continue to bill as a medical necessity.
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