Change Request 12607

1 CMS Manual System Department of Health &. Human Services (DHHS). Pub 100-04 Medicare Claims Processing Centers for Medicare &. Medicaid Services (CMS). Transmittal 11263 Date: February 10, 2022. Change Request 12607 . SUBJECT: Revisions to National Coverage Determination (NCD) (Home Use of oxygen ) and (Home oxygen Use for Cluster Headache). I. SUMMARY OF CHANGES: The purpose of the Change Request is to revise Section and Section of the National Coverage Determination (NCD) Manual (Pub. 100-03), Chapter 1, Part 4, and to inform the Medicare Administrative Contractors (MAC)s of the changes associated with these NCDs effective September 27, 2021.

2 The Centers for Medicare & Medicaid Services finalized revisions to two separate, but medically related, NCDs for oxygen therapy and oxygen equipment in the home. Effective for claims with dates of service on or after September 27, 2021, CMS is revising NCD , Home Use of oxygen , to nationally expand patient access to oxygen and oxygen equipment in the home. oxygen therapy and oxygen equipment is nationally covered in the home for acute or chronic conditions, short or long term, when the patient exhibits hypoxemia, as defined in Subsection B of the revised NCD.

3 Initial claims for oxygen therapy for patients exhibiting hypoxemia must be based on the results of a clinical test that has been ordered and evaluated by the treating practitioner. Secondly, the revised NCD identifies circumstances of non-coverage of home oxygen and oxygen equipment. Thirdly, MACs may determine that coverage of home oxygen and oxygen equipment is reasonable and necessary for patients with a medical need who are not exhibiting hypoxemia (as defined in Subsection B of the NCD) and who are not otherwise precluded by nationally non-covered indications described in Subsection C of the NCD.

4 In addition, CMS is removing NCD , ending coverage with evidence development for home use of oxygen to treat cluster headache, and allowing the MACs to make coverage determinations regarding the use of home oxygen and oxygen equipment for patients with cluster headaches ( as allowed under Section D of the revised NCD ). The Federal government creates NCDs that are binding on the MACs who review and/or adjudicate claims, make coverage determinations, and/or payment decisions, and also binds quality improvement organizations, qualified independent contractors, the Medicare appeals council, and Administrative Law Judges (ALJs) (see 42 Code of Federal Regulations (CFR) section (a)(4) (2005)).

5 An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.). EFFECTIVE DATE: September 27, 2021. *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: June 14, 2022. Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

6 II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated). R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE. R 20 and oxygen Equipment D 20 Evidence of Medical Necessity for oxygen III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a Change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer.

7 If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and Request formal directions regarding continued performance requirements. IV. ATTACHMENTS: Business Requirements Manual Instruction Attachment - Business Requirements Pub. 100-04 Transmittal: 11263 Date: February 10, 2022 Change Request : 12607 . SUBJECT: Revisions to National Coverage Determination (NCD) (Home Use of oxygen ) and (Home oxygen Use for Cluster Headache).

8 EFFECTIVE DATE: September 27, 2021. *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: June 14, 2022. I. GENERAL INFORMATION. A. Background: Medicare previously issued a NCD providing coverage of home oxygen and oxygen equipment only for patients with significant chronic hypoxemia who met the specified medical documentation, laboratory evidence, and health conditions of Section , Home Use of oxygen , of the NCD Manual (Pub 100-03), Chapter 1, Part 4. Also, The Centers for Medicare & Medicaid Services (CMS). reconsidered NCD in 2011, and specified in Section , Home oxygen Use to Treat Cluster Headache, that Medicare provided coverage for the home use of oxygen for cluster headaches through Coverage with Evidence Development (CED).

9 In August 2020, CMS opened NCD based on a formal Request to reconsider Medicare's coverage of the home use of oxygen for cluster headaches. In addition to the formal Request , lessons learned from the COVID Public Health Emergency (PHE) compelled CMS to reconsider the current coverage policy at NCD. to ensure that Medicare beneficiaries have access to home oxygen . B. Policy: Effective for claims with dates of service on or after September 27, 2021, CMS is removing NCD in the Medicare NCD Manual, ending CED, and allowing the Medicare Administrative Contractors (MACs) to make coverage determinations regarding the use of home oxygen and oxygen equipment for cluster headaches (as allowed under subsection D of the revised NCD ).

10 In addition, CMS is revising NCD , Home Use of oxygen , in the Medicare NCD Manual to nationally expand patient access to oxygen therapy and oxygen equipment in the home. 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 in Subsection B of the revised NCD 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. Secondly, the revised NCD , Home Use of oxygen identifies circumstances of non-coverage of home oxygen and oxygen equipment.