CMS Publishes Oxygen for Cluster Headaches NCD Decision
CMS is finalizing changes to two separate, but medically related NCDs that should expand access to the use of home oxygen to treat Cluster Headache.
On Monday, CMS published a decision memo that should expand patient access to home oxygen therapy and equipment, and permit contractors to cover the use of home oxygen to treat Cluster Headache (CH) and other acute conditions.
Specifically, (CMS) is finalizing changes to two separate but medically related National Coverage Determinations (NCDs). It is removing the NCD for Home Oxygen Use to Treat CH (240.2.2) and revising the NCD for Home Use of Oxygen (240.2).
By removing NCD 240.2.2, CMS is ending coverage with evidence development (CED), and allowing the Medicare Administrative Contractors (MACs) to make coverage determinations regarding the use of home oxygen and oxygen equipment for CH.
CMS is also modifying NCD 240.2 to expand patient access to oxygen and oxygen equipment in the home and to permit contractors to cover the use of home oxygen and oxygen equipment to treat CH and other acute conditions.
The update comes a year after CMS requested comments on the two NCDs.
The American Association for Homecare summarized the changes resulting from the decision memo:
- Removes the Certificate of Medical Necessity (CMN) requirement. CMS recognizes that the CMN form is no longer needed for claim processing purposes or medical reviews. CMS replaced the term "recertification" to "renewal" to avoid confusion on the CMN requirement being removed.
- Recognizes that there are limitations with using pulse oximeter to determine blood oxygen levels. It can be useful in estimating blood oxygen levels, but it is not effective in measuring the exact level.
- Expands coverage for acute condition and removes references to ‘chronic stable state’. Initial coverage will be limited to 120 days or less for situations unrelated to hypoxemia. Oxygen coverage can be renewed within 120 days if there is continued need.
- Removes trial of alternative therapies prior to oxygen coverage. CMS believes it is the treating practitioner’s responsibility to determine whether oxygen therapy is reasonable and necessary.
- Recognizes that oxygen therapy is not only needed for lung diseases. NCD discusses ability to breathe as primary driver, not desaturation.
- Provides DME MACs the discretion to determine whether oxygen coverage is reasonable and necessary. However, the NCD is clear that oxygen coverage is available for all patients that need it.
- Broader interpretation of the term ‘exercise.’ CMS will accept functional performance such as climbing stairs, dressing, ambulation, etc. or formal exercise test.
- Defines "time of need" as "during the patient’s illness when the presumption is that the provision of oxygen in the home setting will improve the patient’s condition."
- Removed references to respiratory therapist services. CMS notes that Oxygen NCD should not include clinical services.
AAHomecare noted that CMS did not publish the effective date of the updated Home Use of Oxygen NCD, but the associated reported it has been informed the DME MACs are aware of the announcement and will be working on new Local Coverage Determinations.