Does E0486 require prior authorization?

No, E0486 does not require prior authorization (high confidence). Code is covered without prior authorization.

`E0486` — Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

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.

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.

L33611 — Oral Appliances for Obstructive Sleep Apnea

J19

AETNA-CPB-0688 — Intra-oral Appliances for Headaches and Trigeminal Neuralgia

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

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