Medicare coverage for oral appliances
We have received numerous inquiries from our clients regarding a possible recent change in Medicare policy regarding coverage for custom made oral appliances for Obstructive Sleep Apnea (OSA) (HCPCS code E0486) when the Medicare beneficiary has previously been provided a Positive Airway Pressure (PAP) machine covered under Medicare.
Medicare DME has considered custom made oral appliances for OSA and PAP therapy “same/similar equipment” for several years now – we have not seen a change in those guidelines, however it does appear that same/similar claim edits for custom made oral appliances for OSA and PAP therapy have been increased. These claims generally receive the denial remark “Equipment is the same or similar to equipment already being used."
If you do receive a denial from Medicare DME for same/similar equipment, it is recommended (both by us and in Medicare’s bulletins) that you appeal it using Medicare DME’s redetermination form (first level). Here is a link to it: https://med.noridianmedicare.com/documents/2230703/6501021/Redetermination+Request/65139ed0-93da-47eb-878a-5550d2f57a91
**example: you may have the “reason” listed on this form as “Claim denied due to same/similar equipment. Patient was intolerant/non-complaint to PAP therapy and has already returned the rental PAP machine. No PAP supplies are currently being ordered. Physician prescribed E0486 as alternative to PAP therapy due to patient intolerance/non-compliance.”
If needed, here is the link to the reconsideration form (second level): https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20033.pdf
Here is a link to some additional information provided by Noridian regarding same/similar equipment denials: https://med.noridianmedicare.com/web/jadme/topics/same-or-similar/ss-denials
Also another link provided by Noridian that discusses same/similar equipment and advance beneficiary notices (ABN’s): https://med.noridianmedicare.com/web/jadme/topics/same-or-similar/ss-and-abns
Here is a link to download the ABN, and there is one built right into DentalWriter in the “QuickLetters” tab of any patient chart:
Q: How do I know if the patient has had a PAP provided before? What if the patient doesn’t remember?
A: Medicare’s bulletin states “To verify the patient has not had a same or similar item previously, suppliers can utilize [their jurisdiction’s online provider portal] or the IVR. The supplier enters their NPI, PTAN, last five digits of the Tax Identification Number, the beneficiary's Medicare ID, the beneficiary's first and last name, the beneficiary's date of birth, and the HCPCS code. The IVR and portal research and return the claim history and supplier information for applicable claims processed within this jurisdiction as well as by other DME MACs by researching the Common Working File for that HCPCS code. “
Q: What do I do if I get a Medicare DME claim denied due to same/similar equipment?
A: Medicare’s bulletin states: “If a claim is denied due to same or similar claims previously paid, suppliers can submit a redetermination. Supporting documentation would need to be included with the redetermination request. Examples of applicable documentation include the CMN or DIF, physician order, signed pick up and delivery tickets, a detailed outline of events and any changes in medical need and a copy of the ABN.”
Q: Should I have Medicare patients who have tried PAP before sign a ABN?
A: Medicare’s bulletin states: “If there is no indication that same or similar equipment has been previously obtained, the supplier would not have reason to provide an ABN. If the beneficiary or the beneficiary's authorized representative is unable to respond fully on the issue of "same or similar equipment," the supplier may issue an ABN. In situations where the beneficiary is planning to use a piece of equipment as a backup (e.g., an extra wheelchair to keep in the car), the supplier should always obtain a signed ABN. A signed ABN is indicated on the claim form with a GA modifier.”