HI drpolan!

Great question. This has actually been a big area of argument for quite some time. So – the reason it has been a big area of argument: There are some dentists that have enrolled as Medicare Part B provider in order to bill for the visits that happen prior to the impressions being taken, and then any follow up visits that happen after the 90 day global period for E0486. The Medicare policy for sleep appliances seems to contradict itself, and palmetto released a statement that suggests nothing should be billed outside of E0486 because it is considered all inclusive.

There is a the statement that was released by Medicare indicating that that may not be ok, the statement reads:
“HCPCS codes E0485 and E0486 describe oral devices or appliances used to reduce upper airway collapsibility, adjustable or non adjustable, prefabricated (E0485) or custom fabricated (E0486). These devices are typically used to treat obstructive sleep apnea. Both codes include all fitting and adjustment. These are codes reimbursed as Durable Medical Equipment by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC). Medicare claims related to the fitting, initial/subsequent adjustments, and repairs of an oral device should be submitted to the appropriate DME MAC and not as Evaluation & Management (E/M) services to the AB MAC. Additionally, any radiological or other services performed in order to guide the adjustments of the oral device should not be submitted separately to the AB MAC, as the Medicare Program payment associated with HCPC Codes E0485 and E0486 already includes any required adjustments to ensure a properly fitted device.
After considerable internal study, and with agreement by dental experts at CMS Central Office, Palmetto GBA has confirmed that all services related to the codes - including initial patient evaluation, any required imaging, all fitting and post fabrication adjustments - are contained in the codes and payable only by the DME Medicare Administrative Contractor”

The statement above does seem to pretty clearly indicates that you should NOT be billing Medicare Part B for the initial visit and any x-rays, but doesn’t seem to as clearly address follow up care post 90 days…..

Then, there is language in the LCD:

"Oral appliances generally are classified as dental devices and are not classified as durable medical equipment. The following items (not all-inclusive) are considered to be dental devices and will be denied as non-covered, not DME:

- Oral occlusal appliances used to treat temporomandibular joint (TMJ) disorders
- Tongue retaining devices used to treat OSA and/or snoring
- All oral appliances used only to treat snoring without a diagnosis of OSA
- Oral appliances used to treat other dental conditions
- Oral appliances that require repeated fitting and/or adjustments, beyond the first 90-days, in order to maintain fit and/or effectiveness"


Here is a link to an article in DSP magazine that addresses about the whole “to bill or not to bill Medicare Part B for sleep office visits from the dental practice” situation: https://dentalsleeppractice.com/legal-ledger/medicare-dmepos-friend-or-foe-part-2/

Hope this helps!