Does E0485 require prior authorization?

Yes, E0485 requires prior authorization (high confidence). Code explicitly requires prior authorization.

Verity

`E0485`, Oral device/appliance used to reduce upper airway collapsibility, adjustable or

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires 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.
A Standard Written Order (SWO) must be communicated to the supplier before claim submission; for DMEPOS base items requiring Written Order Prior to Delivery (WOPD), a signed SWO/WOPD must be received before delivery or the claim will be denied.
The treating practitioner must order the sleep test and the practitioner ordering the oral appliance must document review of the sleep test report in the medical record.

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.
A custom fabricated mandibular advancement oral appliance (HCPCS E0486) is covered when the beneficiary has an in-person clinical evaluation by the treating practitioner before the diagnostic sleep test to assess for obstructive sleep apnea (OSA).
Coverage is allowed when a Medicare-covered sleep test shows AHI or RDI >= 15 events/hour with a minimum total of 30 scored events.
Coverage is allowed when a Medicare-covered sleep test shows AHI or RDI between 5 and 14 events/hour with a minimum total of 10 scored events AND documented presence of either (a) excessive daytime sleepiness, impaired cognition, mood disorder, or insomnia, OR (b) hypertension, ischemic heart disease, or history of stroke.
Coverage is allowed when AHI > 30 or RDI > 30 AND the beneficiary is unable to tolerate a positive airway pressure (PAP) device OR the treating practitioner documents that PAP therapy is contraindicated.

16 Active Policies

PALMETTO-JJ-L33428, Cosmetic and Reconstructive Surgery

PALMETTO-JM-L33428, Cosmetic and ReconstructiveSurgery

L33611, Oral Appliances for Obstructive Sleep Apnea

UHC-POL-obstructive-sleep-apnea-treatment, Obstructive and Central Sleep Apnea Treatment

BCBSIL-MED204.006, Medical Management of Sleep Related Breathing Disorders

BCBSMT-MED204.006, Medical Management of Sleep Related Breathing Disorders

BCBSNM-MED204.006, Medical Management of Sleep Related Breathing Disorders

CARELON-sleep-disorder-management-2024-10-20-updated-2025-07-01-for-anthem-bcbs-ohio-medicaid-and-regence-only-deferred-to-2025-12-01, Sleep Disorder Management

BCBSOK-MED204.006, Medical Management of Sleep Related Breathing Disorders

REGENCE-AH36, Prefabricated Oral Appliances for Obstructive Sleep Apnea

UMR-POL-UMR-obstructive-sleep-apnea-treatment, Obstructive and Central Sleep Apnea Treatment

CARELON-sleep-disorder-management-2025-11-15-uc, Sleep Disorder Management

SUREST-POL-SUREST-obstructive-sleep-apnea-treatment-sur, Obstructive and Central Sleep Apnea Treatment – Surest Medical Policy

ANTHEM-SURG.00129, SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

EVICORE-HPLAN-THE_HEALTH_PLAN-424028EDD246, The Health Plan Sleep CPT Code List - Effective 01/01/2026

A53497, Billing and Coding: Oral Maxillofacial Prosthesis

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

E0485, Oral device/appliance used to reduce upper airway collapsibility, adjustable or