HEALTH CARE AUTHORITY
[Filed May 16, 2019, 12:03 p.m.]
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 firstname.lastname@example.org, 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 email@example.com, 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
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.