Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
The rules say a custom fabricated mandibular advancement oral appliance (E0486) used to treat obstructive 
sleep apnea (OSA) is covered if criteria A - D are met. 
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to 
assess the beneficiary for obstructive sleep apnea testing. Refer to the ICD-10 code list in the LCD-
related Policy Article for applicable diagnoses. 
B. The beneficiary has a Medicare-covered sleep test that meets one of the following criteria (1 - 3):  
1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or 
equal to 15 events per hour with a minimum of 30 events: or, 
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:  
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
b. Hypertension, ischemic heart disease, or history of stroke; or, 
3. If the AHI> 30 or the RDI> 30 and meets either of the following (a or b):  
a. The beneficiary is not able to tolerate a positive airway pressure (PAP) device; or, 
b. The treating practitioner determines that the use of a PAP device is contraindicated. 
C. The device is ordered by the treating practitioner following a review of the report of the sleep test. (The 
practitioner who provides the order for the oral appliance could be different from the one who 
performed the clinical evaluation in criterion A.) 
D. The device is provided and billed for by a licensed dentist (DDS or DMD). If all of these criteria (A-D) are not met, the custom fabricated oral appliance (E0486) will be denied as not 
reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) Oral Appliance 
for Obstructive Sleep Apnea L33611. 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.