Medicare Coverage of Oral Appliances: Including Same or Similar-Medicare Coverage of Oral Appliances: Including Same or Similar Slides

Medicare Coverage of Oral Appliances: Including Same or Similar Slides

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The 2025 Annual Meeting of the American Academy of Dental Sleep Medicine (AADSM) focused on Medicare coverage for oral appliances used in treating obstructive sleep apnea (OSA). Various speakers, including professionals from CGS and Noridian, highlighted crucial information related to the coverage criteria, documentation requirements, coding, and resources available to providers.<br /><br />One key aspect addressed was the criteria for Medicare coverage of custom-fabricated mandibular advancement devices. These criteria include a prior clinical evaluation for OSA, a Medicare-covered sleep test, and an order from the treating practitioner. Furthermore, the device must be provided and billed by a licensed dentist. Additionally, coverage is conditional on certain documented sleep test results, such as apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) scores.<br /><br />The event stressed that oral appliances and positive airway pressure (PAP) devices, both used to treat OSA, will not simultaneously receive coverage. Therefore, documentation should ensure clear justification for medical necessity. Providers are required to maintain comprehensive proof of delivery records to ensure compliance and successful claims processing with Medicare.<br /><br />The coding and billing section emphasized the necessity of having a written coding verification. Only devices with specific design criteria, verified by the Pricing, Data Analysis, and Coding (PDAC) contractor, are eligible for coverage using certain billing codes, with prefabricated devices being generally non-covered.<br /><br />Participants were informed of resources and assistance offered by Noridian and CGS Administrators, including customer service lines and online portals to support patient care and adherence to Medicare regulations. The meeting concluded with a reminder on maintaining updated knowledge of Medicare's continuously evolving policies and guidelines.

Keywords

AADSM

Medicare

oral appliances

obstructive sleep apnea

mandibular advancement devices

coverage criteria

coding and billing

documentation requirements

PDAC

Noridian