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Hi Guest!
In order for original/traditional Medicare to offer coverage for custom made oral appliances for OSA, the dental practice must be enrolled as a Medicare DME supplier. Once enrolled, there is actually no pre-authorization required for OAT for OSA.
If you are not currently enrolled, it may be best to refer this patient to a practice that is, as the enrollment process typically takes anywhere between 3-6 months.
Hope this helps!
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Can you please tell me the current (2023)or most recent oral appliance (E0486) reimbursement rate for medicare in CA?
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Rank: Administration
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Hi Guest!
No problem. The allowed amount for Medicare DME for E0486 for California is approx 1636.27
Hope this helps!
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Can you let me know what the most recent reimbursement is for E0486 for Dallas, TX, and where I can find the reference? United Healthcare is stating that since there is no published fee, they only cover 50%. After coinsurance, copay, etc. Edited by user Wednesday, June 28, 2023 4:11:33 PM(UTC)
| Reason: add'l info
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Rank: Administration
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Hi Josh C!
The current allowed amount for E0486 for Medicare DME in Texas is approximately $1,278.
Unfortunately, still as of today, none of the 4 Medicare DME Regions have published the allowed amount for E0486 on their fee schedules! (even though Medicare has officially covered E0486 since 2010).
So, the only real documentation you can offer an insurer who is say this is an EOB from a claim filed to Medicare for E0486 (which shows the allowed amount on it).
Hope this helps!
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Rank: Guest
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Originally Posted by: courtneydsnow  Hi Josh C!
The current allowed amount for E0486 for Medicare DME in Texas is approximately $1,278.
Unfortunately, still as of today, none of the 4 Medicare DME Regions have published the allowed amount for E0486 on their fee schedules! (even though Medicare has officially covered E0486 since 2010).
So, the only real documentation you can offer an insurer who is say this is an EOB from a claim filed to Medicare for E0486 (which shows the allowed amount on it).
Hope this helps! I expect they won't accept that, since it would mean they'd have to actually provide the coverage we pay for, but I appreciate your help!
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Rank: Administration
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Hi Josh!
I have definitely seen insurers accept a copy of an EOB (as long as it is fairly recent) with the PHI blacked out for these types of situations!
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Rank: New Member
Joined: 12/29/2014(UTC)
Posts: 1
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Hello!
Our office is no longer a DME provider - we had signed up but did not successfully send at least one claim within the one year period, so now we are considered non-DME providers.
I have recently been working on a few oral appliance claims for patients. I bill E0486-NU-KX and understand that we are able to charge our full fee due to our non-DME status.
I was recently told that I have to flag all of my claims to Medicare to NOT assign benefit (box 27). Regardless of our DME status, Medicare will NEVER send the benefit check to our office. So...for all of my Medicare oral appliance patients - I must charge them in full up front, and then just let them get a check in the mail?
How have I never heard this before? Even when we were DME providers, I was NEVER told that Medicare won't send checks directly to the office.
Can you confirm, is this true?
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Rank: New Member
Joined: 12/28/2023(UTC)
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For Medicare, the appropriate CPT code for billing an oral appliance for obstructive sleep apnea (OSA) after a confirmed sleep test is E0485.
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