Mild Obstructive Sleep Apnea (OSA) Treatment
Effective April 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) is expanding its coverage for treatment of OSA to include treatment for mild OSA with a Food and Drug Administration (FDA)-approved prescription device. This FDA-approved device is eXciteOSA and will be covered under the agency’s DME benefit. The device will be covered without prior authorization for full-benefit Healthy Connections Medicaid members aged 18 years or older. Eligible members must have a diagnosis of mild OSA, indicated by a sleep study, with a score of apnea-hypopnea index of more than five and less than 15. Medical providers must follow the FDA guidelines for use, indications and contraindications when prescribing the device. The device has the following two units:
Power Source (Control) Unit
One prescription per lifetime is allowed for the power source and control unit.
- During the first two years, repairs or replacement covered under the product manufacturer’s warranty are not billable to SCDHHS. If the power source (control) unit is damaged or lost after two years of usage or ownership, SCDHHS may allow a replacement power source unit with prior authorization. Providers must file the prior authorization request to the SCDHHS Quality Improvement Organization (QIO).
Oral Appliance Unit
The prescription for the oral appliance unit must be renewed annually.
- During the first two years, repairs or replacement covered under the product manufacturer’s warranty are not billable to SCDHHS. If additional units of oral appliance are needed during a 12-month period, the provider must file a prior authorization request to the SCDHHS QIO justifying the need for the additional unit. Only one additional unit may be allowed.
To be eligible for reimbursement for eXciteOSA, South Carolina Healthy Connections Medicaid-enrolled DME providers must maintain a copy of the Medicaid certificate of medical necessity in the patient’s record. DME providers must utilize the following procedure codes, criteria and limitations when billing for the prescription of eXciteOSA:
| Procedure Code | Description | Limitations and Billing | Reimbursement |
|---|---|---|---|
| E0490 | Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, controlled by hardware remote | Allowed one power source and control unit per patient per lifetime; This is a capped rental device. Procedure code may be billed monthly for up to13 months using the following modifiers:
| Months 1-3: Rate is $87.28/month Months 4-13: Rate is $ 65.52/month After 13 months: Device is considered purchased |
| E0491 | Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by hardware remote, 90-day supply | Supply purchase; Oral device allowed one per day, per patient and up to four per 12 months. No modifier is required. | 90-day supply: $78.69 |
South Carolina Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the coverage and reimbursement of services described in this bulletin for members enrolled in an MCO.
Providers should direct any questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Providers can also submit an online inquiry at: https://www.scdhhs.gov/providers/contact-provider-representative.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.