Welcome, good evening everyone. I'm Savita Siddappa, moderator for this evening's webinar on Medicare coverage of oral appliances, including SAME or similar. I'm joined with our speakers, Judy Rohn from CGS, Tanya Gillis, and Mary Reineke Ferguson from Noridian. And now, I will turn it over to the speakers. Well, hello everyone. This is Judy Rohn with CGS. I'd like to thank you all so much for joining us today and thank ADSM for having us today. With me today, again, is Tanya Gillis and Mary Reineke Ferguson from Noridian. I'll be turning the presentation over to Tanya just about halfway through. So with that, we'll go ahead and get started. First we have our conflict of interest disclosure. Because we are the Medicare contractors, we do not have any potential conflicts to disclose or discuss. The objectives of today's presentation, you will be able to know Medicare coverage of oral appliances, understand the documentation requirements, and be familiar with what resources are available to you. So without further ado, we will move into our webinar. The Medicare contractors do include disclaimers in all of our presentations and that basically states that the information provided today is current as of this moment. You should always refer to our website for the most current information. On our agenda today, we will be discussing oral appliance coverage criteria. We'll talk a little bit about same and similar. We'll provide information on documentation requirements. We'll review coding and billing guidelines, provide some resources and as previously discussed, we will be providing answers to your questions. So the first topic on our agenda is coverage criteria. So the coverage criteria, which I'm going to review today, is available in the local coverage determination or LCD and they're available on the CMS as well as the DME MAC websites. So a custom fabricated mandular advancement oral appliance is used to treat OSA or obstructive sleep apnea and it's covered if criteria A through D on this slide are met. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to their sleep test to assess the beneficiary for that OSA. They've had a Medicare covered sleep test. The device itself is ordered by the treating practitioner following a review of the report of that sleep test and of course the practitioner who provides the order for the oral appliance can be different from the one who performed that clinical evaluation in criterion A. And that device is provided and billed by a licensed dentist. Now criterion B is the sleep test. So again, it must be a Medicare covered sleep test. And here are the requirements, an AHI or RDI of greater than 15 events per hour with a minimum of 30 events or two, AHI RDI of greater than five and less than 14 events per hour with a minimum of 10 events and documentation of additional symptoms, including the excessive daytime sleepiness, impaired cognition, mood disorders, insomnia or hypertension, ischemic heart disease or a history of stroke. Or criterion three for the sleep test, if their AHI or RDI is greater than 30, the beneficiary is unable to tolerate a PAP or the treating practitioner determines that a PAP device is contraindicated. And that comes back to the same and similar that we'll talk about in just a few moments. So the initial consultation and follow-up care, they are not billable by the DME supplier, which is the individual providing the oral appliance. The practitioner treating the patient for the OSA determines their treatment and the candidacy for an oral appliance. In this scenario, the dentist is considered the DME supplier and all services included in the benefit for the oral appliance, there is no separate payment made. For follow-up care, all of the follow-up care during that first 90 days is included in the payment for the device. And there is no coverage under the benefit after that initial 90-day period. Now moving into same and similar. Now I know same and similar became a very hot topic in the fall of last year. So we just wanted to provide some clarification on what is considered same and similar with a positive airway pressure or PAP device. So it's important to note that for the majority of Medicare beneficiaries, an oral appliance and a PAP device will not be covered at the same time. There was some information circulating last year that Medicare had removed some obstacles, I used quotes, obstacles of same and similar. And this was misinterpreted to mean that they could be used together. Now because they are used to treat the same condition, the beneficiary should not have both a PAP device and an oral appliance unless it's specific to that beneficiary and there is documentation to justify why they would possibly need both. So the same and similar editing that was updated last year was to address Criterion 3 that we just reviewed. And that's where the beneficiary has the RDI or HI of greater than 30 and they're unable to tolerate PAP or the treating practitioner determines that the PAP is contraindicated. So that's where that editing was removed to avoid that obstacle when submitting claims for oral appliances. Just to clarify that, for most beneficiaries, again, a PAP device and an oral appliance would not be considered for coverage at the same time because again, they are covering the same condition. Moving into documentation requirements, now it's important to note that any claim is subject to audit or review. So when claims are reviewed, we will be looking to confirm that that item meets the Medicare requirements and all of the documentation requirements. So what we would expect to see is a standard written order or SWO. Medical records to justify the coverage criteria are met such as the sleep test and other documentation. Every claim submitted to the DME-MAX must have proof of delivery documentation. Now proof of delivery documentation is required by supplier standard number 12 and it also protects you, the supplier, just in case the beneficiary says, oh, I didn't receive that item. You have that proof of delivery to justify that that item was actually provided to the beneficiary. And of course, the beneficiary's authorization to submit claims on their behalf. Now first is the standard written order. Now you must have a standard written order prior to claim submission and it must include each of the elements listed on the slide. The beneficiary's name or their Medicare beneficiary identifier, MBI, the date of the order, a general description of the item. Now that description can be either a general description such as oral appliance. It can be the HCPCS code. It could be the HCPCS code narrative or it could be a brand name or model number. The quantity to be dispensed. Now this says if applicable. And of course, if you're only providing one, then the quantity is not required. The treating practitioner's name or national provider identifier, NPI, and the treating practitioner's signature. Now some requirements of when a new order must be obtained. For the initial purchase or rental of any item, if there's a change in the order or prescription, when an item is replaced, and if there's change in the supplier and the new supplier did not obtain a valid order from the original supplier. So this is where the beneficiary may have gone to a different doctor to initially receive the item and all of the documentation went to that first doctor. But now for some reason that beneficiary comes to you. So in that scenario, if you cannot obtain that documentation from the other physician, you would want to obtain a new order as well as medical, the existing medical records for that beneficiary. Now there is an exception to the standard written order. It does not have to be a separate document. When the prescribing practitioner is also the supplier, they're permitted to furnish those items of demiposts or durable medical equipment, prosthetics, orthotics, or supplies. Is permitted to fulfill the role of supplier in accordance with any applicable state laws. And a separate order is not required in all these scenarios, but the medical record must still contain all of those elements two slides ago of the standard written order. Now we have seen a lot of denials with CERT or comprehensive error rate testing where they will deny the claim if it is not the correct ordering practitioner. So say the beneficiary's general practitioner or physician treating their, sorry, treating their respiratory condition, their sleep apnea, say they write the order. You're providing the item, but you didn't order it in this scenario. So to avoid errors, when the claim is submitted, be sure to include the ordering practitioner on that particular claim. So it's whoever is on the order is the one that should be submitted on the electronic claim as the referring provider. And I guess at this time, I'm going to go ahead and turn it over to Tanya. Thank you. Thank you, Judy. I'm going to continue on with documentation requirements. We're going to start talking about that medical record. So what are we looking for within that medical record? Well, the medical record should outline the quantity ordered or frequency of use if applicable and should also include the beneficiary's diagnosis, duration of condition, clinical course, the prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and past experiences and related items. This is not an all-inclusive list. We're looking for medical necessity of the item ordered within the medical record to meet those policy criterion. We have been asked by suppliers in the past what format should medical records be recorded. Medicare program does not have any requirements for the media format. However, medical records need to be in its original form or in a legally reproduced form which may be electronic for review. Supplier prepared statements and physician attestations such as letters of medical necessity by themselves do not provide sufficient documentation of medical necessity even if signed by the ordering practitioner. Templates or forms are subject for cooperation from within the medical record and the order can provide additional information of what is required outside of the standard written order. However, that information again must be corroborated within the medical record. For proof of delivery, suppliers are required to main proof of delivery within their documentation or their files for at least seven years. Medical review purposes, the proof of delivery documentation assists in determining correct coding and billing. Medicare must be able to determine from the delivery documentation properly coded items. Items delivered are the same items submitted for Medicare reimbursement and the items are intended for and received by a specific Medicare beneficiary. Suppliers deliver directly to the beneficiary or the designee. The date the beneficiary received the item must be the date of service on the claim. I want to repeat that one more time, date of delivery equals your date of service. A valid delivery slip must include all of the following, the beneficiary's name, the delivery address, again this is the address where the item was actually delivered, a description of the item being delivered and this can include the HCPCC code, the HCPCC code description, brand name, model number, quantity delivered, date delivered, again that date equals your date of service and then the beneficiaries or their designee's signature. Next we're going to review coding and billing. A custom fabricated oral appliance, that E0486, is one that is uniquely made for an individual beneficiary. It involves taking a full arch, negative impression of the beneficiary's teeth, either using appropriate materials or digital images from which a positive model is created. Basic materials are then cut, bent and molded using the positive model in order to construct the final oral appliance. A custom fabricated oral appliance may include a prefabricated component. An example that's provided on the slide is the joint mechanism. The only products which may be billed using the E0486 are those for which our written coding verification review has been made by the PDAC contractor and subsequently published on the product classification list and we have provided the link of PDAC on this slide. As a reminder, the E0485 is not covered and if billed, it will be denied as not reasonable and necessary. We have a coding FAQ that we wanted to provide, questions that we've received in the past. So why does PDAC only approve devices with a fixed mechanical hinge? The answer, there's limited coverage for oral appliances because they must meet the definition of durable medical equipment or DME and in the late 1990s, CMS determined that the HERPS-like appliances meet this requirement. To date, Medicare has not considered any other appliance designs as included in the DME benefit. On this slide, we have modifiers that are associated with this policy. If a modifier is missing from the claim, the claim will be rejected as missing information. Only one of these modifiers is required and it is inappropriate to bill with a combination of KX, GA, GZ modifiers on the same claim line. This slide outlines assigned versus non-assigned claims. Suppliers choose participating or non-participating during enrollment through the National Provider Enrollment or NPE. If you are participating claim by claim, you must accept assignment and receive the Medicare allowable maximum that can be collected. If you are a non-participating supplier, you may accept assignment on a claim by claim basis and collect from the beneficiary the amount charged. You must bill Medicare on behalf of the beneficiary and Medicare will reimburse 80% of the allowed charges directly to the beneficiary on non-assigned claims. Next we're going to review a couple of resources that we have provided within the presentation. Here you can find contact information for Noridian for Jurisdiction A. We've provided our website, our IVR supplier contact center, and telephone reopenings. That is one telephone number and again, this is for Jurisdiction A only. Our Noridian Medicare portal, again, when you're going out to the portal, making sure that you're choosing your jurisdiction correctly and then we have a link here for the LCDs and policy articles. Next we have a resource for Jurisdiction B, which is CGS. We've provided the website, the IVR telephone number, myCGS web portal, customer service phone number, telephone reopenings phone number, and I want to point out that for Jurisdiction B and C that those phone numbers are different, so make sure that you are calling the correct line that you are trying to contact. And then we also have LCDs and policy articles linked here for Jurisdiction B. Jurisdiction C has the same information, however, again, it is detailed for Jurisdiction C. The website for CGS is also listed here, the IVR number, customer service, telephone reopening numbers are also listed, again, noting that they are different for CGS. And then the LCD and policy articles are also listed here. And we are going to end for Jurisdiction D. Our resources for Noridian, our website for Noridian, the IVR, supplier contact center, and telephone reopenings are the same number, however, this number is for Jurisdiction D specifically. The Noridian Medicare portal is also listed here, and of course, following this up with those LCD and policy articles for Jurisdiction D. We wanted to include other contractor resources. Here you can find PDAC, so if you have questions in regards to coding and coding verification, you'll want to reach out to the PDAC contractor. We also have contact information for the Common Electronic Data Interchange, or CEDI. You can reach out to them through their telephone number or through their website. We also included information for the National Provider Enrollment, or NPE, NPE East, Novitas Solutions, and then NPE West, Palo Meadow GBA. You can contact them through either their telephone numbers or the websites that are provided here on this slide. And with that, we will turn it over to Dr. Sadapa in order to answer questions. Okay, thank you for all the information. Okay, if any of the members have any questions for our speakers, please submit them at the question and answer button, and then I will go over all the questions from top to bottom. You can also put a thumbs up, use the thumbs up feature to, for your favorite questions so that can move up the list. Some questions may be answered by the moderator in writing, in which case you will see a text answer under your question. So let's start the questions. Is there any way to submit DME claims without a clearinghouse? Absolutely. This is a great question. So yes, you can submit claims without a clearinghouse. Any supplier can submit claims on their own behalf. Depending on if you submit 10 or less claims per month, you can submit paper claims if you meet some limited exceptions, or you can get some free software from CEDI that Tanya provided that link, and you can absolutely submit those claims without going through a clearinghouse. Thank you. Medicare allows telehealth visits currently through March 31, 2025. Are we allowed to receive those telehealth office notes until then? This is Tanya, and yes, as long as it's an approved telehealth, we will accept those notes through March 31, 2025. In order to find out if it's an approved telehealth, we have links on our websites in order to research that. Again, you would want to go to our websites, look up telehealth, and it will provide more information in regards to approved telehealth. Thank you, Tanya. And I'd just like to add that telehealth is not actually ending as of March 31, 2025. The waivers and flexibilities are what's ending. So telehealth will have to be handled through an – it'll still have to be an approved visit. So telehealth isn't going away. I think there's a misinterpretation in the industry about that, but it is changing and going back to the way it was before the COVID-19 PHE. Because the DME MACs do not process the claims for the telehealth, we always suggest that suppliers contact the telehealth physician to confirm that that claim was billed to the AB MAC to confirm it is a valid telehealth visit. Thank you. I have a couple of questions submitted before the webinar, so I'm going to go over them. What sort of verification happens to ensure that the device is provided by and billed by a licensed dentist? Well, that information would be handled by the NPE contractors or the National Provider Enrollment contractors. So when you signed up to get your supplier number to be able to provide these items, all of that occurs during enrollment. So all of those licensure requirements must be met to provide these items on the enrollment process. Thank you. Some dentists are starting to use teledentistry, so the patient takes their own impression at home rather than the dentist taking it in the office. Does Medicare allow this? These items are custom fit and must be custom fit by the dentist. Okay. Thank you. Okay. Can you clarify if we are able to or not able to bill out an office visit for initial consultation that is prior to delivering the appliance? Any fitting or office visits are included into the cost of the actual device within those first 90 days. Anything outside of those 90 days is not within the scope of the DME MAC, as you would not bill the DME MAC for an office visit. Okay. Okay. If the patient is not severe, AHI less than 30, and they turn in their CPAP, are they then eligible for an OAT benefit since they would not be using them at the same time? They could be. If the CPAP device was returned and there would have to be documentation that the beneficiary wasn't using that item and it was returned, then the oral appliance could be covered at that time as long as they meet the coverage criteria. Okay. Perfect. I think the next one follows with that question. The more common situation I see is the beneficiary tries CPAP and fails but has tried for longer than three months. Does the same or similar still restrict the treatment for those patients and force them to wait five years before treating their OSA? You are absolutely correct. So if the beneficiary – it does tie right into that last question. If the beneficiary returns that device, they're not compliant with the PAP device, in that scenario, if there's documentation of a, quote, quote, pickup, slip, or return, then we can consider coverage of the oral appliance. Okay. Even if it is past three months. Correct. Okay. Perfect. Thank you. Does 10 events mean during the sleep study or a minimum of 10 AHI? So for the 10, the minimum of 10, it must be for the sleep study and also it's 10 events per hour and have that excessive daytime sleepiness, impaired cognition, or any of those other conditions, the ischemic heart disease or stroke. When Medicare is paying for a CPAP, however, the patient is not using it, would they need to return the CPAP prior to getting an oral appliance for OSA to avoid same or similar? Yes. This is what Judy had reviewed within the presentation. You stated the treating practitioner can write the SWO. Does that mean the dentist can write it? No, it does not. So it's actually the physician who is interpreting the sleep test, and it must be within your scope of practice to order. If the PCP ordered the sleep study but was referred to a sleep doctor, can you just put the name of the sleep doctor in the name of the PCP? Yes. Okay. Reviewing that sleep test would be the one that would have to order. If the PCP ordered the sleep study but was referred to a sleep doctor, can you just put the sleep doctor on the claim because the sleep doctor signs the LON? It would actually have to be the physician who ordered the item would have to be the physician submitted on the claim. Okay. I'm sorry. Let me clarify. Not necessarily ordered the sleep test. The physician who actually ordered the oral appliance would be the one submitted on the claim to the DME MAC. Sorry about that. Sorry to interrupt. Okay. No worries. Does the same and similar apply if PAP is over 90 days and no longer used? If it's not being billed to Medicare and if they're receiving the oral appliance afterwards, then there shouldn't be an issue with same or similar. However, if there is a denial received, submit through appeals and let the appeal staff know that the PAP is no longer being utilized and has been returned and now their beneficiaries meeting for the oral appliance. The SWO should still be signed by the physician, not the DDS, correct? Also, does the same similar apply to a five-year rule between PAP rental over 90 days and the OA? This has not changed, has it? So I think we previously addressed the order issue. So, yes, that should be completed by the physician. Also, for same and similar, if the beneficiary has so to address all of the same and similar questions, if the beneficiary has a PAP device and they have not returned it and it is still renting or it is still reasonable and necessary for that beneficiary, that an oral appliance would not separately be considered. So that should address all of the oral appliance same and similar questions. Yeah. Do you see CPT code K1027 becoming payable by Medicare in the near future? I absolutely have no comment on that. We have no comment. Okay. On what basis does Medicare use to determine that appliances without a metal hinge do not qualify for E0486? When the rule for Medicare to cover oral appliances occurred back in, I believe, 2015, that's when the item with the metal hinge was decided to be durable medical equipment and fell under the DME benefit. I thought same and similar was eliminated this year. I understand the patient can't have CPAP and OA simultaneously. But what if the patient stops using CPAP after a year or two and then ordering a physician provides a medical reason for stopping? Or the patient simply can't use it? Can the patient then get an OA? If the PAP device is still reasonable and necessary, then, of course, Medicare is not going to cover both items. If the item has been returned or it is no longer reasonable and necessary for that beneficiary, there must be documentation to substantiate the change and why it is no longer reasonable and necessary for them. And at that point, the oral appliance would be considered for coverage. And again, as I mentioned earlier, and I know it went viral in the industry, same and similar went away. Same and similar did not go away. What occurred was some edits were turned off to allow for a beneficiary to receive an oral appliance if they were unable to tolerate a PAP device. So just to provide clarification on that, same and similar still applies for oral appliances and PAP. And the only time that a beneficiary would be able to receive both at the same time is if there are extenuating medical circumstances to justify that need. If Medicare has paid for a CPAP within five years and becomes intolerant, will Medicare then pay for an OLAPS? I think you just answered that question. We've answered the same and similar question. Yes. They keep asking it a million times. And some of these may have come in before we clarified. So it's been answered. It's been answered, yes. If a patient has, oh, yeah. If the patient has stopped using CPAP and they have a new sleep study to meet the 12-month criteria for a new diagnosis, are they eligible for a new treatment order for an oral appliance? Same answer as previously provided. Yeah, I know. There would need to be documentation. Yeah. Is there an age limit on a diagnostic sleep study prior to an oral appliance fitting? We have heard 12 months. So 12 months is incorrect. It should be a relatively recent sleep test because, of course, if this beneficiary has sleep apnea, that condition needs to be treated as quickly as possible. So Medicare does not have a formal timeline for the age of the sleep test. However, it should be relatively recent. What about using the K1027 code? If you want reimbursement, as Tanya covered under our coding guidelines, unfortunately, the only item that is currently covered is the E0486. All right. What is the best way to get started in Medicare? How do we know what the reimbursement will be for our area? Oh, that's two wonderful questions, and, Tanya, I'll let you answer a few after this one. So the best way to get started with Medicare is to start with enrollment. So you have to be enrolled as a DME supplier to be able to provide these devices. So Tanya did provide the NPE information, National Provider Enrollment Contractors. So that's where you want to start to be able to provide those items. And reimbursement, it's a custom device, so there is no specific fee schedule. If you would like to know what the reimbursement is for your area, I would suggest talking to other dentists who provide these items within your area. How old could the sleep study be? I know you said recent, but like- There's no, well, there's no black and white timeframe, so it will, the answer will always be recent. It will never be three months, six months, 100 years. Unfortunately, there is no specific timeframe, but it should be relatively recent because, again, the beneficiary has a condition that must be treated. Yeah. Can we get a copy of this? We've provided a copy, so if you're able to provide that to all on the call, that's fine with us. Okay. Will telemedicine still be available in future? And we've answered this. Judy expanded upon this. And as far as we know, it's not a DME thing, that it's more of a Part B thing, so you'd want to make sure that it is covered under Part B. And, again, going out to our website so you can find more information on telehealth. Okay. As a non-PAR, can you bill patient for initial consult? I think we went over that. Yeah, we went over that. Is there a timeframe for the sleep study we went over that? Late 90s seemed a long time ago. Why no more approved appliances? Well, that one could be a few reasons. And one reason could be perhaps there haven't been devices submitted to the PDAC for consideration. I can't really answer for the pricing data analysis and coding contractor. But currently, as we addressed, and that's why we had a frequently asked question, the only current item is the one with the metal hinge. Yeah. What is a telephone reopening? Telephone reopening is a correction to a claim, clerical error within your claim. So if you billed with incorrect maybe the submitted amount or place of service or modifiers, you'll have to resubmit for modifiers. But you can call telephone reopenings and they can help you out in getting those claims corrected. Okay. Can you go over the Medicare pre-authorization workflow? Absolutely. There is no prior authorization for these items through Medicare. Now, remember, we're talking about traditional fee-for-service Medicare. So always keep that in mind when we're talking about the DME-MAX. Tanya, Mary, and I are all representing the DME-MAX. We are not representing Medicare HMOs or any other insurers or Medicaid for Medicare. Traditional fee-for-service Medicare, there is no prior authorization. Does it mean for the previous one, probably? Will the information on the slides be available on the website after tonight? Randy, are you providing the attendees copies of the presentation? Yes. A PDF of the slides will be available with the recording. There you go. I thought a TAP device was PDAC approved. I am not familiar with what a TAP device is. But for Medicare billing, the only currently covered item is the E0486. Yeah. I think they should look at the approved devices. That's probably the best way to go with that. Did I understand the IRBST appliance is the only covered appliance by Medicare plans? Correct. The E0486 is the only device that's covered by Medicare fee-for-service. And, again, going out to the PDAC contractor, it lists everything out there. And that is part of the presentation. We've provided that link. We had read the regions A and D were no longer checking applying the same and similar rules for oral appliances when CPAP had been delivered in the past five years. I think this has been addressed. We've talked about the same and similar rules. A and D is following the same as jurisdictions B and C. If you are not participating, non-participating, or opted out, can you still treat a Medicare recipient using ABN forms? If the supplier number requirements are not met, that is one reason to utilize an advanced beneficiary notice of non-coverage. If Noridian no longer can be checked for the same and similar, how are we to know if the appliance might be denied for same and similar? You should be able to check same or similar to see if they have one on file, a current one on file. If there's any issues, you can call their contact center, and they'd be able to help you out with history. Who exactly is CGS and Noridian? Is this a group that dentists work with to do billing for Medicare? No, we're actually the Medicare contractors that process the claims for durable medical equipment, orthotics, prosthetics, and supplies, including oral appliances. So we're here speaking for the traditional fee-for-service Medicare contractors. Can you be specific about post-sleep study discussion by the referring MD? Can you provide additional information as to what you're asking? Did you address if CPAP and the oral appliances are still considered same and similar? I think a lot of these questions came in about 20 minutes ago. Yes, I think a lot of them were early. Yeah, they were probably coming in during the same and similar. Yeah. Maybe start working from the bottom up. Maybe. Yeah, it's very similar. We have addressed all these questions. Yeah. This one's a little different. So for the same and similar, we've still been getting denials for oral appliances. How would this be fixed? A note from the doctor stating why CPAP is intolerable? So if you've received a same and similar denial because there's a PAP device in history, you can request an appeal with documentation, your first level of appeal, which is redeterminations, with documentation that perhaps the PAP device has been returned, or there's a change in condition, or the beneficiary cannot tolerate that PAP device. There must be documentation from the ordering physician to justify why the PAP is no longer effective for that beneficiary. Okay. I think maybe we can answer this one. What if patients stopped using PAP but his DME company refuses to take it back? What happens with that patient? Can they get an EOA? So in this scenario, the beneficiary can contact 1-800-Medicare. If the supplier is continuing to bill and they're not using it, they can contact 1-800-Medicare and express that to them. And we can do some research on the DME MAC side to see if the beneficiary is continuing to use the device. If not, then we would consider doing an overpayment if that beneficiary is still using it. If not, then we would consider doing an overpayment if that beneficiary is no longer utilizing it. Once the overpayment is done, then Medicare could allow for the oral appliance. How the dentist bill under Part B for evaluation visits? That is a wonderful question. And we are not Part B. I would strongly suggest referring to the limited, very limited Part B criteria for dentistry. I know that all the Part Bs have policies, but this most likely would not be billed to Part B because it's included in the device itself. But you would want to contact Part B about that. Okay. This one. When an office enrolls, can any dentist working at that office provide the appliance? That's a question for the National Provider Enrollment Contractor. I found one, trying to help, there are a lot, I understand completely, there are wonderful questions, they really are great questions and I'm glad we're here to address them. So when you say the name needs to be the same for the order, are you saying that applies for the sleep physician or the dentist? So if the sleep physician wrote the order, that is the individual that should be submitted on the claim. Is a new order not needed in this example? If the patient goes to Dentist 1, decides they don't want it from Dentist 1, they now go to Dentist 2, we get patients who originally saw a dentist then come to us because of their treatment experience. So in that scenario, you must either obtain the original order from the other supplier or from the ordering physician, or you must get a new order in that scenario. I think we covered most of it. If there is anything that's unanswered, please submit so we can. I see one that wasn't addressed, I'll try. What is the process for the beneficiary to receive both a PAP and an OAT for patients that have significant documentation from their physician? So when you submit the claim, you want to make sure that you have all of that documentation available upon request. If that claim is denied, then you would need to send that documentation through the appeals process. If not, you would need to continue to retain that documentation in case it was requested. Are dentists allowed to offer home sleep tests for their sleep patients? I would absolutely not be able to answer that. Again, I think it's a scope of practice issue, so I can't answer that question. I see a question. When can EO486 still be in your standard of care? There are no products in any field forced to be used that are antiquated 30 years old. I'm thinking of being forced to use a 30-year-old car design, computer, or cell phone. They're stuck in the past. So many great designs and innovations that are not within EO486, all proven by current studies and clinical proof. All of that information would need to be submitted to a policy reconsideration, which I have not seen a policy reconsideration for oral appliances in the 20 years that I've been with Medicare. So a reconsideration would need to be submitted. All of the DME MACs have that on their LCD page where you could submit a reconsideration. And manufacturers could submit coding requests through the PDAC. So it does fall into the onus of the manufacturers as well as the industry to provide that information to Medicare for reconsideration. I'm going to capture these last couple of questions here. I have one asking about the ABN, is there a specific time that the ABN must be signed by the patient? It needs to be signed prior to delivery. Beneficiary needs to have enough time to make a decision in regards to if they want that item, if they're not meeting medical necessity of that item. So it needs to be signed on the date of delivery or prior to the date of delivery. There's a question here in regards to the Medicare Advantage Plan. We are, as Judy has stated a couple of times, we are Medicare fee-for-service. We cannot answer questions in regards to Medicare Advantage Plans. You would have to reach out to them directly if you have questions. Another question, does a letter of medical necessity always need to be done for Medicare even if we have a prescription and referral? Letter of medical necessity, and we might be talking two different things, we have different language. I have found between clinicians and Medicare, a letter of medical necessity is not part of the medical record. It is just a letter written that kind of outlines what's in the medical record. That would have to be corroborated within the actual medical record. That's what we utilize in order to meet the coverage criteria of the local coverage determination. There's questions in regards to claims being submitted electronically. We do have information in regards to CEDI within the presentation, and we talked about that a little bit early on in our questions. And then for appeals, can they all be sent together if they are multiple? This was not allowed before. We would prefer that if you're submitting your appeals that you submit them one for one with all your documentation for that beneficiary put together so there is no confusion if you're trying to submit multiple appeals for multiple beneficiaries. We both, I believe, CGS, Judy, you can confirm this, CGS is able to submit appeals through the portal? Yes, that is correct. You can submit your appeals through NERIDIAN's portal or CGS's portal and that's one for one. And I'll go ahead and answer a proof of delivery question as well. For proof of delivery, is this just clinical notes or a specific form made for this? So slide 23 of the presentation, which will be provided with the recording by AADSM, does refer to the requirements. It's also in our standard documentation requirements policy article available on the DME MAC web pages. But slide 23 does review what elements are required in your proof of delivery documentation. So you do have to have specific documentation to justify proof of delivery. Any questions? That's the time we have for the questions. That was a great presentation.

Medicare

oral appliances

obstructive sleep apnea

coverage criteria

documentation requirements

billing guidelines

custom-made devices

CPAP intolerance

telehealth visits