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Coverage criteria policies

Oral appliances for sleep disorders – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for oral appliances for sleep disorders.

Coverage

Oral appliances for sleep disorders are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

For patients who cannot tolerate a continuous positive airway pressure (CPAP) machine, a physician may prescribe an oral appliance. The oral appliance is considered Durable Medical Equipment. Dentists assure the proper fit of the appliance. Most appliances require that a dentist take necessary impressions and a bite registration.

  1. For a custom fabricated appliance to be covered, criteria A-D must be met:
    1. A face-to-face evaluation by a physician prior to a sleep test to assess the client for obstructive sleep apnea testing
    2. The sleep test must meet one of the following three criteria:
      1. The apnea-hypoxia index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events
      2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of one of the following (a or b):
        1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia
        2. Hypertension, ischemic heart disease, or history of stroke
      3. The AHI is greater than 30 or the RDI is greater than 30 and meets either of the following (a or b):
        1. The enrollee is not able to tolerate a positive airway pressure device
        2. The treating physician determines that the use of a positive airway pressure device is contraindicated
    3. A physician must order the device following review of the report of the sleep test (the physician who provides the order for the oral appliance could be different from the one who performed the clinical evaluation in criterion A.)
    4. The device is provided and billed for by a dentist
  2. Quantity limits: one per five years

Definitions

A custom fabricated oral appliance (E0486) is one that is individually and uniquely made for a specific patient. It involves taking an impression of the patient's teeth and making a positive model of plaster or equivalent material. Basic materials are used with the positive model to produce the final product. Custom fabrication requires more than trimming, bending, or making other modifications to a substantially prefabricated item. A custom fabricated oral appliance may include a prefabricated component (for example, the joint mechanism).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

Codes

Description

E0485

Oral device or appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment.

E0486

Oral device or appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

For in-network benefits to apply, item must be received from a contracted vendor or provider.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Dental Services (Overview). Revised: 12-22-2017.
  2. Minnesota Health Care Programs (MHCP) Medical Supply Coverage Guide. Revised: 04-09-2018.

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Policy activity

  • 05/17/2018 - Date of origin
  • 06/01/2018 - Effective date

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