Oxygen and Oxygen Equipment

Revision Effective Date: 04/01/2023
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: "Beneficiaries do not change group classification when going from initial coverage to continued coverage based upon changes in blood oxygen testing results" (effective 09/27/2021)


04/20/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to updates to National Coverage Determination 240.2.

Revision Effective Date: 04/01/2023
CODING INFORMATION:
Added: N1, N2 and N3 modifiers


02/23/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are non-discretionary updates to CMS HCPCS coding determinations.

Revision Effective Date: 01/01/2023
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: “For all the overnight oximetry criteria described above, the 5 minutes does not have to be continuous.” under Overnight Oximetry Studies (effective 09/27/2021)
Removed: “otherwise the Group III presumption of non-coverage applies” under Overnight Oximetry Studies (effective 09/27/2021)
Removed: “for 5 minutes total (which need not be continuous)” under criterion 4 for overnight oximetry testing for beneficiaries with OSA (effective 09/27/2021)


01/12/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to updates to National Coverage Determination 240.2.

Revision Effective Date: 01/01/2023
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: Language in regard to CMS’ codification of nationally covered and non-covered indications fo
r home oxygen and oxygen equipment within the NCD Manual section 240.2 and section 1862(a)(1)(A) of the SSA (effective 09/27/2021)
Added: "therapy and oxygen equipment" after statements of "oxygen" and "home oxygen"
Added: "and oxygen equipment" after statements of "oxygen therapy" and "home oxygen therapy"
Added: "Initial coverage" of home oxygen therapy (effective 09/27/2021)
Revised: Reasonable and necessary criteria for Groups I and II home oxygen therapy and oxygen equipment (effective 09/27/2021)
Removed: References to "chronic stable state" (effective 09/27/2021)
Added: Coverage criteria for Group III home oxygen therapy and oxygen equipment (effective 09/27/2021)
Added: Group IV criteria
Removed: Long Term Oxygen Therapy (LTOT) Clinical Trials
Removed: “CLUSTER HEADACHES (CH)” section and related information
Added: “cluster headaches” as a medical condition example in Group III
Removed: All references and instructions for the Certificate of Medical Necessity
Added: Group I, II or III for high liter flow allowance criteria
SUMMARY OF EVIDENCE:
Removed: Summary of evidence information, due to not being applicable to the non-discretionary changes
ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):
Removed: Analysis of evidence information, due to not being applicable to the non-discretionary changes
CODING INFORMATION:
Removed: Q0 modifier
APPENDICES:
Removed: Cluster headaches and LTOT special coverage rules
SOURCES OF INFORMATION:
Added: Home use of Oxygen and Home Oxygen Use to Treat Cluster Headaches Decision Memorandum (CAG-00296R2)
Added: Home Use of Oxygen Decision Memo (CAG-00296R3)
Removed: “CR7235 for cluster headache trial"
BIBLIOGRAPHY:
Removed: Bibliography information, due to not being applicable to the non-discretionary changes


11/17/2022: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to updates to National Coverage Determination 240.2, removal of National Coverage Determination 240.2.2 and CMS Change Request (CR) 12734: Elimination of Certificates of Medical Necessity and DME Information Forms.

Revision Effective Date: 08/02/2020
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: "physicians" to "treating practitioners
Removed: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related PA
Added: Statement to refer to ICD-10 codes in the LCD-related Policy Article
GENERAL:
Revised: Order information as a result of Final Rule 1713
SUMMARY OF EVIDENCE:
Added: Information related to topical oxygen
ANALYSIS OF EVIDENCE:
Added: Information related to topical oxygen
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO
BIBLIOGRAPHY:
Added: Section related to topical oxygen
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments (A58247)

Revision Effective Date: 01/01/2019

COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
 Removed: NCD language
 Removed: Statement to refer to diagnosis code section below
 Added:
Refer to Covered ICD-10 Codes in the LCD-related Policy Article

HCPCS CODES:
Added: HCPCS E0447
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
 Moved: All diagnosis codes to the LCD-related Policy Article diagnosis code section per CMS instruction
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
 Moved: Statement about noncovered diagnosis code moved to LCD-related Policy Article noncovered diagnosis code section per CMS instruction

Revision Effective Date: 08/01/2018
HCPCS MODIFIERS:
Added: Modifiers GA, GY, GZ, KX


06/07/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Revision Effective Date: 04/01/2018
Coding Information
Revised: Modifier QE, QF, QG
Added: Modifier QA, QB QR


04/19/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Added: General Requirements
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Direction to Standard Documentation Requirements
Removed: Miscellaneous section
Removed: PIM citation from Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article

Effective July 1, 2016 oversight for DME MAC LCDs is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the LCDs.

Revision Effective Date: 10/31/2014
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation Language to add who can enter date of delivery date on the POD
POLICY SPECIFIC DOUMENTATION REQUIREMENTS:
Revised: Diagnosis code references for Cluster Headaches