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#1 Posted : Sunday, September 16, 2018 7:43:23 PM(UTC)

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Is it necessary to have a DME to provide an oral appliance for treating sleep apnea in a Medicare patient? If the patient and I agree on a fee and to not file for Medicare benefits, why would we need a DME?

If we acquire a DME, is it necessary to opt in or out of Medicare? If so, should we opt in as an ordering/referring dentist? All questions refer to providing sleep apnea oral appliances.

I understand Medicare only replaces an appliance every 5 years. What happens if an appliance is lost or severely damaged?

#2 Posted : Tuesday, September 18, 2018 4:46:24 PM(UTC)

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Hi Guest,
If you have not opted out of Medicare, you will want to have a patient sign an advanced beneficiary notice (ABN).

When enrolling as a Medicare DME supplier for oral appliances for OSA, you don't want to "opt out of being in-network", but rather you have two options when enrolling as a DME supplier:

1) enroll as a participating DME supplier (meaning you bill accept Medicare's allowed amount for E0486 as payment in full and not balance bill anything beyond any applicable deductible & coinsurance)

2) enroll as a non-participating DME supplier (meaning you have the option on a claim by claim basis to either "accept assignment" or "not accept assignment". Accepting assignment means you will not balance bill above Medicare's allowed amount, not accepting assignment meaning you can balance bill up to your usual fee since there is no "limiting charge" for this DME item).

Medicare's LCD for oral appliances for OSA specifies a 5 year replacement period. Here is the language from the LCD below:

"Oral appliances are eligible for replacement at the end of their 5-year reasonable useful lifetime (RUL). These items may be replaced prior to the end of the 5-year RUL in cases of loss, theft, or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). Replacement due to wear-and-tear as the result of everyday use will be denied as statutorily non-covered prior to the expiration of the 5-year RUL."

Hope this helps!
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