Tip of the Week – August 1-5, 2016

The effective date for the new Premera Blue Cross medical policy for Oral Appliances for Obstructive Sleep Apnea (OSA) has been pushed back yet again! Currently, it is listed to go into effect on November 1, 2016 so we wanted to make sure you are aware of the changes!

View the updated policy

For custom made oral appliances, the new policy states:

“Custom Fabricated (E0486)

For custom molded and fabricated oral appliances the following criteria must be met:

Custom-made intraoral appliances may be considered dentally/medically necessary as an alternative to a prefabricated intraoral appliance, when the following criteria are met:

  • Documented attempt and failure of a prefabricated device (E0485). Documentation must include:
    • 3 or more months of clinical history indicating failure to successfully wear a prefabricated appliance; OR
    • Type II or type III malocclusion so severe that a prefabricated appliance would not be successfully fitted or worn.
  • If the AHI is 30 events per hour or greater and meets either of the following:
    • The patient is not able to tolerate a positive airway pressure (PAP) device; OR
    • The use of the PAP device is contraindicated.”

For pre-fabricated oral appliances, the updated policy states:

“Prefabricated (E0485)

For individually fitted, ready-made oral appliances the following criteria must be met:

  • The AHI is between 5–30 events per hour, including a minimum of 10 events documented per sleep study.”


For dates of service prior to November 1, 2016, you can view the current policy below:

View the current policy

Premera Blue Cross lists the following e-mail address on their website for questions regarding medical policies: medicalpolicy@premera.com


Want to learn more about Crosscoding from dental to medical insurance? We have wonderful courses scheduled throughout the country all year for Successful Medical billing in Dentistry, CBCT, sleep apnea appliances, oral surgery and TMD! You can view our full course schedule with more details below:

View Schedule or Register

Please let us know if you have any questions at 1-800-879-6468, or contactus@dentalwriter.com.

Best Regards,
The Nierman Team