WSR 19-11-068
PROPOSED RULES
HEALTH CARE AUTHORITY
[Filed May 16, 2019, 12:03 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 19-05-017.
Title of Rule and Other Identifying Information: WAC 182-552-0450 Mandibular advancement device.
Hearing Location(s): On June 25, 2019, at 10:00 a.m., at the Health Care Authority (HCA), Cherry Street Plaza, Sue Crystal Room 106A, 626 8th Avenue, Olympia, WA 98504. Metered public parking is available street side around building. A map is available at https://www.hca.wa.gov/assets/program/Driving-parking-checkin-instructions.pdf or directions can be obtained by calling 360-725-1000.
Date of Intended Adoption: Not sooner than June 26, 2019.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 42716, Olympia, WA 98504-2716, email arc@hca.wa.gov, fax 360-586-9727, by June 25, 2019.
Assistance for Persons with Disabilities: Contact Amber Lougheed, phone 360-725-1349, fax 360-586-9727, telecommunication relay services 711, email amber.lougheed@hca.wa.gov, by June 21, 2019.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is adding coverage limits for mandibular advancement devices.
Reasons Supporting Proposal: See purpose.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Michael Williams, P.O. Box 42716, Olympia, WA 98504-2716, 360-725-1346; Implementation and Enforcement: Joan Chappell, P.O. Box 45510, Olympia, WA 98504-2716 [98504-5510], 360-725-1071.
A school district fiscal impact statement is not required under RCW
28A.305.135.
A cost-benefit analysis is not required under RCW
34.05.328. RCW
34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. This rule making does not impose any additional cost[s] or requirements on providers.
May 16, 2019
Wendy Barcus
Rules Coordinator
NEW SECTION
WAC 182-552-0450Mandibular advancement device.
The agency covers the purchase of a mandibular advancement device for a client when the provider determines that the use of a continuous positive airway pressure (CPAP) device is medically contraindicated or the client cannot medically tolerate a CPAP device. Prior authorization is required for all eligible clients.
(1) The agency considers a mandibular advancement device to be medical equipment subject to the same billing requirements, restrictions, and limitations as other medical equipment according to chapter 182-543 WAC.
(2) For clients:
(a) Age twenty and younger, if this device is recommended during the early and periodic screening, diagnosis, and treatment (EPSDT) exam and then ordered by a provider, the agency evaluates the health care service according to WAC 182-534-0100.
(b) Age twenty-one and older who have natural dentition, the agency pays for one custom-made mandibular advancement device every five years. The client must:
(i) Complete a face-to-face evaluation with a sleep medicine physician in an agency-designated center of excellence (COE) prior to sleep testing;
(ii) Be diagnosed with obstructive sleep apnea (OSA) using a clinical evaluation and positive attended polysomnogram (PSG); and
(iii) Either meet the sleep testing criteria described in WAC 182-552-0400 or score above thirty on the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI).
(3) The provider must keep the following in the client's record:
(a) Documentation of a CPAP trial lasting at least six consecutive months; and
(b) A description of why CPAP failed or an explanation of why CPAP is not the appropriate treatment.
(4) The mandibular advancement device must be titrated by a licensed provider who has documented experience in titrating these devices.
(5) The mandibular advancement device must be provided and billed by a licensed dentist who:
(a) Holds a certification in dental sleep medicine from the American Board of Dental Sleep Medicine (ABDSM); or
(b) Is the dental director of a dental sleep medicine facility accredited by the ABDSM; or
(c) Has completed agency-recognized continuing education in dental sleep medicine provided by the ABDSM or a comparable organization within the two years prior to ordering the mandibular advancement device.