Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options Duals services for Home Oxygen Therapy.
Definitions
Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.
Prior Authorization
Prior authorization is required.
Procedures
Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Local Coverage Article (LCA) information, as well as other CMS sources, using the links below.
Post-payment Audit Statement
The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement.
Place of Service
The proper place of service for home oxygen therapy is in the home setting.
Coverage Determination and Links
HHO Duals follows the coverage determinations made by CMS as outlined in either the NCD or the state-specific LCD/LCA.
CMS Link
NCD/LCD Links
· NCD: Home Use of Oxygen (240.2)
· LCD: Oxygen and Oxygen Equipment (L33797)
Related NCD: Home Oxygen Use to Treat Cluster Headache (CH) (240.2.2)
Article Links
LCA: Oxygen and Oxygen Equipment - Policy Article (A52514)
Note: Accessories, including but not limited to, trans-tracheal catheters (A4608), cannulas (A4615), tubing (A4616), mouthpieces (A4617), face tent (A4619), masks (A4620, A7525), oxygen conserving devices (A9900), oxygen tent (E0455), humidifiers (E0555), nebulizer for humidification (E0580), regulators (E1353), and stand/rack (E1355) are included in the allowance for rented oxygen equipment. The supplier must provide any accessory ordered by the treating practitioner.
Only rented oxygen equipment is eligible for coverage under this policy. Purchased oxygen equipment is non-covered.
Oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the patient’s treatment.
Respiratory therapist services are non-covered under the DME benefit.
Reimbursement
Participating facilities ill be reimbursed per their HHO Duals contract.
References
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) 240.2 Home Use of Oxygen. Effective date September 27, 2021. Implementation date January 3, 2023. Accessed on July 10, 2023.
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) 240.2.2 Home Oxygen Use to Treat Cluster Headache (CH). Effective date September 27, 2021. Implementation date January 3, 2023. Accessed on July 10, 2023.
Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination: Oxygen and Oxygen Equipment (L33797). Original effective date October 1, 2015. Revision Effective date April 1, 2023. Accessed on July 10, 2023.
Centers for Medicare and Medicaid Services (CMS). Local Coverage Article (LCA) Oxygen and Oxygen Equipment - Policy Article (A52514). Original effective date October 1, 2015. Revision Effective date April 1, 2023. Accessed on July 10, 2023.
Contact Us
For questions related to this policy, contact the Highmark Government Market Policy Team at GovernmentPolicy@Highmark.com
