I am under Medicare and have Part B and G (supplemental). I find the Medicare website done in such a way that no human can easily find anything. I did find a link to Medicare and sleep apnea dental appliances:
https://aasm.org/medicare-coverage-for-oral-appliances-for-patients-with-obstructive-sleep-apnea/
if I read this right, you can't get a sleep apnea dental appliance unless it is medically certified you can't tolerate CPAP or a doctor says you can't use CPAP for some medical reason. It does say, that if this is the case, you can use a "custom" dental appliance which I think would mean most any appliance as they are all custom. Didn't see one or two being mention but you have obviously done more reseach on it than I. We have a couple sleep dentists on this forum so hopefully one of those doctors can supply some real insight.
CMS has very stringent rules for oral appliances. At present there are 22 appliances that are contracted with the Price coding analysis segment of the government (PDAC). 14 of these appliances are various forms of Herbst appliances, but are all made by different laboratories often designed to get a piece of the Medicare pie. Some are cast metal and very thin, some have bulky proprietary hardware. Those that are not Herbst or TAP devices are the Medley Gold, OASYS with lingual lifters or nasal dilators and the SnoreHook Splint (similar to a TAP).
Be aware that Medicare has recently gone through a system wide update and will only pay to treat your sleep apnea once every 5 years. This includes CPAP OR an oral appliance. If you have received a CPAP machine , covered by Medicare, and find yourself unable to tolerate it, Medicare will not pay for an oral appliance until 5 years has passed. The reverse is also true. This means you have to think about costs involved. An oral appliance is custom made and has to be bought outright. CPAP is based on monthly rental and, therefore, may be more affordable out-of-pocket.
Discuss the options of therapy with your sleep physician and the costs involved. While mild-moderate sleep apnea can be treated with an oral appliance as a first line option, severe sleep apnea (the only life threatening level of sleep apnea) is best treated with CPAP. Oral appliances can control sleep apnea in only 30% of patients with severe OSA.
B. Gail Demko, DMD Assoc. Editor Journal of Dental Sleep Medicine Expert Adviosr to the FDA
Ms. Demko, Thanks for your input. I personally am not very good figuring out what Medicare is trying to say or where to find the information I am looking for. As far as a CPAP machine, when a person is prescribed a machine, Medicare contracts with the DME and pays for it in 12 payments. After the 12th payment and the machine is paid for, the individual keeps/owns the machine. Just wanted to make a clarification. What also was not addresses is if a person has medical reasons for changing the type of oral appliance or the type of PAP machine (say needs to from CPAP to BiPaP), will Medicare pay inside of the 5 year window?
As a sleep dentist, I know they will not pay for another or a different oral appliance in less than 5 years and one day after paying for the initial appliance.
As to PAP; If the machine is not yet paid for and your physician decides to put you on a different machine, it would be up to the company supplying the machine to switch you to the new machine, but is not mandatory. If the CPAP is fully paid for, there will be no more funds from Medicare until 5 years and 1 day has passed.
B. Gail Demko, DMD
Assoc. Editor of the Journal of Dental Sleep Medicine
Expert Advisor to the FDA on Oral appliance Therapy
Past President of the Academy of Dental Sleep Medicine
American Board of Dental Sleep Medicne
When you say that oral appliances can control sleep apnea in only 30% of patients with severe OSA what efficacy standard are you applying? Arthur B. Luisi, Jr., D.M.D.
Reducing AHI to below 5 and resolution of symptoms is the standard accepted definition of success with a treatment for sleep apnea. Many authors use a looser definition of success, as do ENT surgeons, of decreasing the AHI by 50% and bringing the final AHI <20 because it makes their treatment look better. The recent trend has been to report data with all accepted definitions of success (there are at least 6 that include AHI data) so that studies can be compared in reviews as more data is generated. Any single study cannot be used to determine any trend unless it includes really large numbers of patients. Oral appliance literature is always problematic because there are such small numbers of patients.
One study about the new diagnosis of high blood pressure, in those with sleep apnea, lumedp moderate sleep apneics with mild sleep apneics but Marin, JAMA 2012 (1886 subjects) showed that the incidence of high blood pressure in those with untreated moderate sleep apnea is much higher than those with untreated mild sleep apnea; all groups with untreated sleep apnea had a higher probability of a new diagnosis of high blood pressure than those who had no sleep apnea at all; this trend was not seen in the Sleep Heart Health Study - but most of those patients had only mild sleep apnea. Dr. Redline would know better than I about medical outcomes in those with untreated mild or moderate sleep apnea since she is an author on many similar papers.
The FDA recently had a workshop with representatives of all those involved in treating sleep apnea. This includes AASM, ASA, neurologists, pulmonologists, ENTs and dentists. One of the questions addressed is exactly what should be the criteria for 'success' when presenting an oral appliance or other device to the FDA. An interesting discussion took place and AHI was considered to be only part of the equation, but one that can be easily quantified.
Information on this meeting can be found at: https://www.gpo.gov/fdsys/pkg/FR-2018-03-08/html/2018-04629.htm A paper will be written and published on the outcome decisions.
B. Gail Demko, DMD
Sleep Dentist Consultant to MyApnea.Org
Assoc. Editor of the Journal of Dental Sleep Medicine
Expert Advisor to the FDA on Oral appliance Therapy
Past President of the Academy of Dental Sleep Medicine
American Board of Dental Sleep Medicine
We will all certainly be better off when there is consensus on oral appliance therapy efficacy. What I try to do on this forum is to take a practical, nuts and bolts, approach to helping patients with their immediate problems. As "WiredGeorge", a sleep enthusiast, has rightly pointed out, people seldom come to this forum if they are doing well. They need help now. In the absence of solid definitions, it falls to the patients to decide what their priorities are. If someone has failed CPAP and is miserable and non-functional, is it sufficient to use an oral appliance if it allows them to sleep well at night and to be alert and functional during the day and when driving, even if the treatment is insufficient to protect them from some of the adverse medical outcomes that would be addressed by CPAP. Well, it is their life and their choice to make.And so on. Arthur B. Luisi, Jr., D.M.D., The Naples Center for Dental Sleep Medicine. Practice partner, dental sleep medicine, NCH Healthcare System, Practice partner, dental sleep medicine, The Millenium Physician Group.
The PDAC list is available at: https://www.dmepdac.com/dmecsapp/ProductClassification/Search
Or, from any search engine, type in 'PDAC'- click
You will come to a page with the name 'Noridian' on the left. Noridian sets the guidelines for ALL DME items for CMS (Medicare)
Below the name 'Noridian,' on the left, is a list of topics. The first is 'home' but the second is 'Search for DMECS for Codes and fees'.
Click on this line.
Next will come a series of boxes. The last on the left is : Search DMEPOS Product Classification List - double click this box.
Up will come " Search DMEPOS Product Classification List with boxes to fill in.
In the box : HCPCS Code. Type in E0486 - then click 'search'.
This will bring you to the list of oral appliances covered by Medicare and which laboratories can fabricate them (ergo 14 different styles of Herbst device). As you scroll down, you will notice that some were approved and then lost their Medicare coverage (effective end date) some got it back; others did not because they did not meet the definition of a Medicare covered appliance. Those with no date in the 'effective end date' continue to be covered by Medicare.
Have fun!
B. Gail Demko, DMD
Sleep Dentist Consultant to MyApnea.Org
Assoc. Editor of the Journal of Dental Sleep Medicine
Expert Advisor to the FDA on Oral appliance Therapy
Past President of the Academy of Dental Sleep Medicine
American Board of Dental Sleep Medicine
