`K1027` Oral dev without fix mech

Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 1 units per day (clinical), rationale: Nature of Equipment
Outpatient hospital: max 1 units per day (clinical), rationale: Nature of Equipment
DME supplier: max 1 units per day (clinical), rationale: Nature of Equipment

Payer policies and prior authorization for K1027

33 of 33 payer prior-auth lists that name K1027 require prior authorization or set conditions: Blue Cross and Blue Shield of Texas, CarePlus Health Plans, Humana, Molina Complete Care (Virginia), Molina Healthcare of California, Molina Healthcare of Idaho, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Oxford Health Plans, Passport by Molina Healthcare (Kentucky).

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)	Medicaid	VA	prior auth required		Apr 1, 2025	Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Idaho	Medicaid	ID	prior auth required		Jan 1, 2025	Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jan 1, 2022	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required		Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Jul 1, 2026	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Texas	STAR	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of Texas	STAR+PLUS	TX	prior auth required		Feb 19, 2025	Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required		Oct 1, 2022	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Utah	Medicaid	UT	prior auth required		Jan 1, 2025	Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Oxford Health Plans	Oxford Health Plans	All	prior auth under conditions	Notification/prior authorization required only for DME codes listed with a retail purchase or cumulative rental cost of more than $500.	Oct 1, 2026	Prior Authorization Requirements for Oxford Effective October 1, 2026

Payer coverage policies that name K1027

K1027 appears in 17 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Shield of California, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Intra-oral Appliances for Headaches and Trigeminal Neuralgia (0688)	not covered	Dec 29, 2025	payer document
Aetna	Obstructive Sleep Apnea in Adults (0004)	covered if criteria are met	Oct 6, 2026	payer document
Aetna	Obstructive Sleep Apnea in Children (0752)	covered if criteria are met	Oct 30, 2025	payer document
Blue Cross & Blue Shield of Mississippi	Sleep Disorders (L.2.01.415)	listed, no stance		payer document
Blue Shield of California	Medical Management of Obstructive Sleep Apnea Syndrome (8.01.67)	listed, no stance		payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Medical Management of Sleep Related Breathing Disorders (MED204.006) HCPCS Codes A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034,	listed, no stance	May 15, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (CS116.AM)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (2026T0525UU)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for Kansas Only) (CS116KS.03)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for Kentucky Only) (CS116KY.16)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for Nebraska Only) (CS116NE.AI)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for New Jersey Only) (CS116NJ.AK)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for New Mexico Only) (CS116NM.E)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for North Carolina Only) (CSNCT0525.12)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for Ohio Only) (CS116OH.G)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for Pennsylvania Only) (CS116PA.AL)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Obstructive and Central Sleep Apnea Treatment (for Tennessee Only) (CS116TN.AN)	listed, no stance	Jul 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Nov 1, 2025: PA removed, Blue Cross and Blue Shield of Illinois
Feb 19, 2025: PA added, Molina Healthcare of Texas
Feb 19, 2025: PA added, Molina Healthcare of Texas
Jan 1, 2023: PA added, Molina Healthcare of Ohio

Medicaid fee-for-service

Prior authorization required or conditional in CO, IN, OH.

OH: $600.00 (dme), effective Oct 1, 2021
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

K1027 Oral dev without fix mech