YESTERDAY
In the early days OAT devices were coded by the Centers for Medicare and Medicaid Services (CMS) under E1399 “Durable Medical Equipment Miscellaneous.” At that time reimbursement was scarce and required tedious documentation. Understand that the HCPCS Coding System is established by CMS and used across the private payer spectrum for device DME description, however reimbursement is an individual decision by each payer.
In 2006 two new E codes were established by CMS. E0485 described a non-custom oral appliance (prefabricated or boil n’ bite). E0486 described a custom fabricated appliance that required taking an impression and creating a model for fabrication. Manufacturers were instructed to identify their device type: custom or non-custom and apply to the PDAC, which is the contracted coding arm of CMS. Reimbursement continued to be sporadic and was not honored by all payers including CMS.
In 2011, the CMS DME MAC contractors in coordination with the PDAC set out to further describe OAT devices within the individual code sets as there were an increasing number of manufacturers making appliances.
E0486 now required a fixed mechanical hinge (front, sides or palate), a 1mm or more patient controlled mandibular advancement mechanism to remain in position during sleep and no required provider adjustment beyond the initial 90-day fitting period. Any devices that did meet this requirement were to be coded A9270. E0485 stayed in the CMS HCPCS code listing but was no longer reimbursed by Medicare.
Of note, the fixed mechanical hinge definition for E0486 comes from the Herbst device, which was developed in 1909 by Emil Herbst as an orthodontic ‘bite jumping’ appliance. In 1979 Hanz Pancherz made additional modifications to the Herbst and added the application for helping patients with Obstructive Sleep Apnea (OSA). The Herbst description was a way for the Medicare contractors to minimize the onslaught of OAT applications that incorporated many different dorsal fin, elastic band and strap designs. As we know the Herbst design uses two hinges, one on either side that must be adjusted equally to maintain balanced protrusion.
TODAY
The new description for E0486 sent many manufacturers scrambling and ultimately creating their own version of the non-patented Herbst design. Today approximately 70% of the PDAC cleared E0486 devices (78 total) are based on the Herbst device, except for the unique TAP design that employs one midline (front) mechanical hinge that is easily adjusted by the patient.
In 2021 CMS was again being flooded with applications for devices that did not have a fixed mechanical hinge. This led to an additional code K1027, that classified the onslaught of custom devices without a fixed mechanical hinge.
COVERAGE
Today there are 3 codes getting reimbursed in their own specific areas (Figure 1).
E0486 consistently has coverage from Medicare, Tricare, the VA and Private Carriers. The guidelines for reimbursement vary by the individual plan and carrier. To determine the exact allowable, you must contact the specific carrier before submission. Reported allowable ranges from $1,100 – $2,900.
K1027 has limited coverage from some private payers depending on the individual plan and carrier. Medicare, Tricare and the VA do not reimburse for K1027. To determine coverage, you must contact the specific carrier before submission. Reported allowable from some plans can range from $1,000 – $2,600.
E0485 has very sporadic and limited coverage with an allowable that can potentially range from $183 – $735.
Figure 1: OAT code coverage based on specific (not all) plans within a carrier
|
CODE |
Medicare |
Tricare |
VA |
BC/BS |
Cigna |
United |
Aetna |
|
E0486 |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
K1027 |
No |
No |
No |
Variable |
Yes |
Yes |
Variable |
|
E0485 |
No |
No |
No |
Variable |
Variable |
Variable |
Variable |
TAP PDAC Letters
All custom TAP devices (TAP 3, dreamTAP, flexTAP, and Nylon flexTAP) are PDAC (Pricing, Data Analysis and Coding) contractor-verified for Medicare reimbursement: Code E0486.
