Did Medicare Recently Start Denying Claims for Your Patients' Oral Appliances? Here's Why.

A few months ago, dental sleep medicine providers began receiving denials from the Centers for Medicare and Medicaid Services (CMS) for their patients’ oral appliances. What many long-time clinicians found particularly vexing is these device claims for patients with obstructive sleep apnea were similar to previous claims that had been paid. So what changed?

First, what has not changed: Under the federal regulations detailed at 42 CFR 414.210(f), the reasonable useful lifetime (also known by the abbreviation “RUL”) of durable medical equipment is 5 years. RUL has always applied to same or similar services. Pertaining to obstructive sleep apnea (OSA), Medicare has always considered positive airway pressure devices and oral appliances to be a same or similar service.

What changed is in March of 2018, a system update was applied that connects positive airway pressure devices and oral appliances in the system and no longer allows for claims to be adjudicated as they were in the past. The system update is effective in all 4 jurisdictions (though implementation date may vary). Providers are not notified of system updates. The update is resulting in patients whose claims are being denied under the reasonable useful lifetime regulation; that is, if an OSA patient tried CPAP within the last 5 years, they can be denied for an oral appliance under RUL. Even if the patient has since returned the positive airway pressure and is no longer on rental, RUL still applies. A Medicare beneficiary who has rented or purchased a positive airway pressure (PAP), which includes continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP), or has been issued an oral appliance within the past 5 years that has been covered under their Medicare durable medical equipment (DME) benefit will have an automatic denial of a claim upon processing.

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