A4575 Medicare coverage

Local coverage indication

Topical hyperbaric oxygen chambers (A4575) will be denied as not reasonable and necessary. Topical oxygen delivery systems (E0446) will be denied as not reasonable and necessary. REFILLS OF OXYGEN CONTENTS: For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. Oxygen contents are reimbursed with a monthly allowance covering all contents necessary for the month. Supply allowances are not subject to the refill monitoring and documentation requirements specified in Chapter 5 of the Medicare Program Integrity Manual. All other supplies, e.g. tubing, masks or cannulas, etc., are included in the monthly rental payment. Supplies that are not separately payable are not subject to the refill monitoring and documentation requirements specified in Chapter 5 of the Medicare Program Integrity Manual. See the Non-Medical Coverage and Payment Rules section of the LCD-related Policy Article for additional information about coverage of oxygen contents. A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary. For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

Excerpt from LCD L33797 version 50, effective 04/01/2023. CMS LCD L33797.

What NCD 240.2 says the item is

A. General When used in the home, oxygen and oxygen equipment can make meaningful contributions to the treatment of patients with both acute and chronic conditions who require the medical gas on either a short- or long-term basis.

National coverage indication, NCD 240.2

B. Nationally Covered Indications Oxygen therapy and oxygen equipment is covered in the home for acute or chronic conditions, short- or long- term, when the patient exhibits hypoxemia as defined below. Initial claims for oxygen therapy for hypoxemic patients must be based on the results of a clinical test that has been ordered and evaluated by the treating practitioner. Such a test is usually in the form of a measurement of the partial pressure of oxygen (PO2) in arterial blood. A measurement of arterial oxygen saturation obtained by ear or pulse oximetry, however, is also acceptable when ordered and evaluated by the treating practitioner and performed under his or her supervision or when performed by a qualified provider or supplier of laboratory services. A durable medical equipment (DME) supplier is not considered a qualified provider or supplier of laboratory services for purposes of this National Coverage Determination (NCD). This prohibition does not extend to the results of blood gas tests conducted by a hospital certified to do such tests.

Excerpt from NCD 240.2 version 2. CMS NCD 240.2.

What NCD 240.2.1 says the item is

A. General Oxygen is a colorless, odorless gas that comprises 21 percent of the atmospheric gases at sea level. Historically, long term supplemental oxygen has been administered in higher than atmospheric concentrations to patients with chronic hypoxemia, generally resulting from cardiac and/or pulmonary disease. The need for supplemental oxygen is assessed by direct or indirect measurement of the partial pressure of oxygen (conventionally expressed in millimeters of mercury, mmHg) and the oxygen saturation of hemoglobin in arterial blood (expressed as a percent). Chronic oxygen therapy is generally administered via nasal cannulae, face mask, or tracheostomy, from a stationary or portable oxygen tank or an oxygen concentrator. The medical literature documents health benefits as well as serious adverse events associated with supplemental oxygen use.

National coverage indication, NCD 240.2.1

B. Nationally Covered Indications Effective for services performed on or after March 20, 2006 the home use of oxygen is covered for those beneficiaries with arterial oxygen partial pressure measurements from 56 to 65 mmHg or oxygen saturation at or above 89% who are enrolled subjects in clinical trials approved by the Centers for Medicare & Medicaid Services and sponsored by the National Heart, Lung & Blood Institute (NHLBI). C. Nationally Non-Covered Indications N/A D. Other This policy does not alter Medicare coverage for items and service that may be covered or non-covered according to the existing national coverage determination for the home use of oxygen provided outside the context of approved clinical trials (National Coverage Determination Manual, section 240.2 and 310.1 ). (This NCD was last reviewed April 2006)

Excerpt from NCD 240.2.1 version 1. CMS NCD 240.2.1.

What NCD 270.4 says the item is

An accepted procedure for healing decubitus ulcers is to remove dead tissue from the lesions and to keep them clean to promote the growth of new tissue. This may be accomplished by hydrotherapy (whirlpool) treatments.

National coverage indication, NCD 270.4

Hydrotherapy (whirlpool) treatment for decubitus ulcers is a covered service under Medicare for patients when treatment is reasonable and necessary. Some other methods of treating decubitus ulcers, the safety and effectiveness of which have not been established, are not covered under the Medicare program. Some examples of these types of treatments are: ultraviolet light, low intensity direct current, topical application of oxygen, and topical dressings with Balsam of Peru in castor oil.

Excerpt from NCD 270.4 version 1. CMS NCD 270.4.

From L33797

Items covered in this LCD have additional policy-specific requirements that must be met prior to Medicare reimbursement. Refer to the LCD-related Policy article, located at the bottom of this policy under the Related Local Coverage Documents section for additional information.

CMS source L33797

From A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs

GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific

CMS article A55426