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#1 Posted : Thursday, March 15, 2018 2:41:12 PM(UTC)

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We are a non participating medicare provider. If the patient wants to get a non medicare covered sleep appliance will medicare still pay their portion and the patient will pay the difference?
#2 Posted : Friday, March 16, 2018 8:40:45 AM(UTC)

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Hi drlmdds!

Great question. It depends! The short answer is likely, no. However! Here's the deal:

When you bill Medicare for a custom made oral appliance for OSA that is not PDAC approved, the LCD instructs you to code the appliance as A9270 instead of E0486.

A9270 stands for: non-covered item or service

So of course, likely the claim will be denied, but you can appeal it so it goes to medical review if there is a good medical reason why the patient did not get an appliance that is PDAC approved. If it was just a preference with no good reason, they may not cover.

I would certainly be sure to have the patient sign an ABN so that if Medicare ultimately does not cover it, the patient is responsible for payment.

Hope this helps!
#3 Posted : Monday, March 28, 2022 7:59:03 AM(UTC)
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