Medicare Administrative Contractors (MACs) are denying coverage for oral appliance therapy for the treatment of obstructive sleep apnea (OSA) in cases in which:
- A patient has been prescribed positive airway pressure (PAP) therapy as the initial treatment for OSA;
- The PAP rental period has been fulfilled; and
- The order for the oral appliance is within a 5-year window from the start date of PAP therapy.
The reasonable useful lifetime (RUL) for durable medical equipment (DME) is 5 years, and DME MACs do not have discretion to change the 5-year RUL. Exceptions to this timeframe can only be made if program instructions authorize a specific RUL of less than 5 years for an item. Once Medicare has reimbursed for an item, a different item used to treat the same condition, although not an identical replacement, is denied as not “reasonable and necessary” (same and similar), if the second item is billed within the 5-year timeframe.
It is common for a Medicare beneficiary with OSA to be prescribed an initial trial of PAP therapy only to find that they are unable to tolerate the PAP device within the first 90 days of initiating therapy. As noted in the Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718), if the treating practitioner does not submit the required 31- to 90-day recertification documentation to the supplier, Medicare reimbursement for the PAP device will cease.
In this scenario, the beneficiary can immediately try to obtain Medicare reimbursement for an oral appliance. However, coverage will not be predicated on a failed PAP trial, but rather the beneficiary will have to meet all the coverage requirements specified in Local Coverage Determination (LCD): Oral Appliances for Obstructive Sleep Apnea (L33611).
Questions and/or clarifications about this policy should be directed to your MAC.
