E0485 — Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- When billing implants with CPT 21299, include an explanation of intended use (that the implant secures/attaches/supports a maxillofacial prosthesis) on the claim.
- Include dates of trauma or tumor biopsy/resection, dates of radiation treatment, and other pertinent medical history in the medical record supporting the need for the maxillofacial prosthesis and implants.
- Initial assessment and diagnostic services to determine appropriateness of an OSA appliance are billable to the Part B contractor (E/M and diagnostic CPTs) only up to the time of the decision to order/provide the appliance; at that decision point all fittings, adjustments, supplies and services become inclusive under the HCPCS appliance payment.
- Claims for provision, fitting, subsequent adjustments, and repairs of an oral device must be submitted to the appropriate DME MAC rather than as E/M services to the A/B MAC.
Key Coverage Criteria
- Implants to secure, attach, or support a maxillofacial prosthesis are covered when the prosthesis is being used secondary to maxillofacial surgery or repair of traumatic injury.
- Oral appliance devices for treatment of obstructive sleep apnea (OSA) are covered using HCPCS E0485 (prefabricated, adjustable or nonadjustable) or E0486 (custom fabricated); both codes include device fitting and adjustment.
- Dermabrasion is covered when used to correct skin defects resulting from traumatic injury, prior surgery, or disease.
- Septoplasty is covered for septal deviation causing nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least 6 weeks.
- Septoplasty is covered for recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy.
- Reconstructive surgery is covered for abnormal structures caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors, or disease when performed to improve function or approximate a normal appearance.
10 Active Policies
L33611 — Oral Appliances for Obstructive Sleep Apnea
J19
ANTHEM-SURG.00129 — SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
A53497 — Billing and Coding: Oral Maxillofacial Prosthesis
L33428 — Cosmetic and Reconstructive Surgery
CARELON-sleep-disorder-management-2025-11-15 — Sleep Disorder Management
Related Codes
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