E1399 — Durable medical equipment, miscellaneous
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- 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.
- Sleep test documentation must include the AHI or RDI value, total number of scored events, recording/sleep duration, and evidence that the test device is FDA-approved and meets Medicare NCD/LCD requirements.
- Proof of delivery (POD) must be maintained by the supplier and made available on request; lack of POD will result in denial.
Key Coverage Criteria
- 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.
- The oral appliance must be ordered by the treating practitioner after review of the sleep test report.
- The appliance must be provided and billed by a licensed dentist (DDS or DMD).
20 Active Policies
L33791 — Walkers
J19
L33830 — Pressure Reducing Support Surfaces - Group 1
J19
L33822 — Glucose Monitors
J19
L33794 — External Infusion Pumps
J19
L33611 — Oral Appliances for Obstructive Sleep Apnea
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