Attention: This bulletin has been superseded and is inactive.
EEOICPA BULLETIN NO.: 15-02
Issue Date: April 17, 2015
________________________________________________________________
Effective Date: April 17, 2015
________________________________________________________________
Expiration Date: April 17, 2016
________________________________________________________________
Subject: Authorizing Oxygen Therapy Durable Medical Equipment (DME) and Oxygen Medical Supplies
Background: The Energy Employees Occupational Illness Compensation Program Act (EEOICPA) provides for medical benefits to covered employees. Specifically, 42 U.S.C. §7384s(b) and §7385s-8 provide that a covered Part B or Part E employee shall receive medical benefits under §7384t of the EEOICPA. Section 7384t(a) states: “The United States shall furnish, to an individual receiving medical benefits under this section for an illness, the services, appliances, and supplies prescribed or recommended by a qualified physician for that illness, which the President considers likely to cure, give relief, or reduce the degree or the period of that illness.”
Physicians prescribe Oxygen Therapy Durable Medical Equipment (DME) and Oxygen Medical Supplies to treat patients diagnosed with different forms of pulmonary disease. Some examples of Oxygen Therapy DME and Oxygen Medical Supplies include stationary and portable oxygen concentrators, gaseous and liquid oxygen delivery systems, cannulas, tubing, regulators, etc.
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is responsible for ensuring that employees with an accepted illness receive authorization for those appliances and supplies medically necessary to give relief to the illness. In an effort to enhance the consistency and timeliness of Claims Examiner (CE) authorizations for Oxygen Therapy DME and related Oxygen Medical Supplies, DEEOIC is updating its procedural guidance with the issuance of this Bulletin.
References: 42 U.S.C §7384s, §7384t, §7385s-8
Purpose: To provide enhanced, uniform procedures that establish guidelines for reviewing authorization requests related to Oxygen Therapy DME and Oxygen Medical Supplies to include: the removal of steps for evaluating rental vs. purchase, repairs and maintenance of Oxygen Therapy DME, and to describe the criteria required to establish a claimant’s medical need for each item prescribed by a physician (M.D. or D.O.). The enhanced procedures will ensure requests are properly evaluated and that authorizations for Oxygen Therapy DME or Oxygen Medical Supplies are completed in a manner that meets the medical needs of the claimant as described by his/her treating physician.
Applicability: All staff.
Actions:
1. All requests for the rental or purchase of oxygen equipment require prior authorization by the CE assigned to the case file. The CE reviews the request to ensure the submitted evidence establishes a clear medical necessity to treat or relieve the effects of an accepted work-related illness. The claimant, authorized representative, the treating physician, or DME supplier may submit requests for authorization of Oxygen Therapy DME and/or Oxygen Medical Supplies to the Bill Processing Agent (BPA) via fax or mail. If the District Office (DO) receives a request directly or via the Central Mailroom, the CE forwards the request to the BPA. All requests submitted for authorization are to include the following:
· Claimant information such as name, case file number, date of birth, and telephone number.
· Oxygen supplier information such as name, facility or business address, billing provider number, Tax ID number, national provider identification number (NPI), telephone number, and fax number.
· Ordering/treating physician contact information such as name, address, telephone number, and fax number.
· Oxygen equipment billing code(s) (HCPCS/CPT), modifier(s), quantity, purchase price or rental price, total cost, begin date, end date, duration of use and frequency.
· Diagnosis code(s) for the condition(s) for which the item(s) is being prescribed.
· Supporting documentation that provides the need for Oxygen Therapy Equipment and/or Oxygen Medical Supplies (i.e., prescription, narrative Letter of Medical Necessity (LMN), supporting medical documentation).
Once the BPA receives an authorization request, it creates an electronic record of the request and initiates an electronic communication (referred to as a “thread”) to the Fiscal Officer (FO) at the appropriate jurisdictional office managing the claim. The thread from the BPA contains instructions to the FO notifying him or her of a pending request for rental or purchase of Oxygen Therapy DME and/or Oxygen Medical Supplies. Upon receipt of the thread from the BPA, the FO forwards the information to the appropriate CE for review and adjudication.
2. Upon receipt of the request for rental or purchase of Oxygen Therapy DME and/or Oxygen Medical Supplies, the CE evaluates the medical evidence to determine if there is sufficient justification to authorize the request as medically necessary for the treatment or care of an accepted condition. The medical evidence that the claimant needs to submit to establish the medical necessity of Oxygen Therapy DME or Oxygen Medical Supplies includes:
a. A signed LMN identifying the specific type of Oxygen Therapy Equipment and/or Oxygen Medical Supplies required to treat the accepted condition in the claim. The content of the LMN is to provide the physician’s description of the medical need for the prescribed Oxygen Therapy DME and/or Oxygen Medical Supplies related to the treatment, care or relief of the accepted work-related illness or illnesses. In lieu of an LMN, the physician may present evidence or any other form/certificate that allows for the narrative reasons justifying the care. To ensure that the physician’s opinion derives from a recent physical assessment of the claimant’s medical status, the physician is to document or identify that a face-to-face visit/evaluation occurred between the claimant and the physician prescribing the DME within six (6) months prior to the date that the physician orders the Oxygen Therapy DME. The physician’s narrative is to communicate clearly the reason(s) why, based on the results of the physical examination and review of available diagnostic evidence, oxygen therapy is medically necessary for the claimant’s accepted work-related illness or illnesses. Finally, the physician is to identify the type or mode of Oxygen Therapy DME to be dispensed, liter flow, duration of use, and frequency.
b. Diagnostic testing that supports the physician’s reasons for prescribing Oxygen Therapy DME or Oxygen Medical Supplies and identifies clear, objective pulmonary deficits including results from an arterial blood gas (ABG) and/or resting/exercise spirometry test, and/or nocturnal oximetry studies. The results are to identify the conditions under which the test(s)/studies were performed; (i.e., during exercise, at rest, or during sleep). The test(s) are to have been performed by a qualified medical professional, and originated from a qualified source such as a laboratory, diagnostic testing facility, hospital, physician’s office or clinic.
3. Upon receipt of the LMN and the diagnostic testing, the CE is to conduct a complete assessment of the medical documentation to ensure that sufficient justification exists for the authorization of Oxygen Therapy DME or Oxygen Medical Supplies. The CE should evaluate the evidence to ensure that the required evidence is part of the case record, including that a face-to-face examination has occurred within the stipulated periods. If the CE decides the evidence is deficient in some manner, for example, the physician has not provided a clear description of the needed DME, or has not provided information on the duration or use of the prescribed equipment, he or she is to undertake development. The CE sends a letter to the claimant and a copy to the physician advising that the DO has received a request for Oxygen Therapy DME and/or Oxygen Medical Supplies, but without the required supporting documentation. The development letter to the claimant and copy to the physician is to include a description of the medical documentation needed as listed in Action Item 1. The CE is to include a statement granting the claimant 30 calendar days to provide the requested information, along with notice that a lack of response or submission of insufficient evidence will result in a denial of the request. The CE documents this request through Correspondence in ECS. A sample development letter can be found in Attachment 1.
a. If, after 30 days of attempted development, and upon review of the evidence, the CE determines there is insufficient evidence to warrant either initial authorization or reauthorization for the rental or purchase of Oxygen Therapy DME and/or Oxygen Medical Supplies, the CE sends a letter decision to the claimant. The letter decision is to include a narrative explanation as to why the evidence is insufficient to warrant authorization. The CE is to send a copy of the letter decision to the provider, if applicable. The letter decision is to include the following language:
If you disagree with this decision and wish to request a formal decision, please immediately advise this office, in writing, that you wish to have a Recommended Decision issued in this case, providing you with your rights of action.
4. Upon issuance of the denial letter, the CE creates Correspondence in ECS documenting the issuance of the decision letter denying the rental/purchase of the equipment/supplies. Upon completion and mailing of the letter, the CE sends an email to the FO denying the request for the rental/purchase of the equipment/supplies. The FO then transmits this information, via thread, to the BPA.
5. Once the medical necessity for Oxygen Therapy DME is established, the CE moves on to assess whether it is appropriate to authorize a short-term rental, continuous rental, or purchase of the requested DME. For authorization of equipment rentals, the DEEOIC will make monthly payments for the approved equipment. A rental period for oxygen equipment is equal to 1 month (30 or 31 days) and is equivalent to one (1) unit of service. When oxygen equipment is purchased, the DEEOIC will make a one-time payment not to exceed the total allowable amount as set by the OWCP Fee Schedule.
a. If the request for oxygen equipment is for a period of 90 days or less; and the diagnostic testing performed substantiates that the test results were obtained during a period of acute status, not reflective of a chronic (usual, typical and stable) state, oxygen equipment shall be reimbursed on a monthly rental basis according to the OWCP Fee Schedule. The rental reimbursement amount includes delivery, set-up, education, and training for the claimant and is not separately reimbursable.
(1) In emergency or urgent situations (such as being discharged from the hospital to home), the CE can authorize up to a 30-day rental period, while additional development is undertaken. Under these circumstances, the claimant, the authorized representative (AR), or the treating physician contacts the DEEOIC’s BPA for immediate attention. The BPA obtains any pertinent documentation such as LMN, discharge plan/summaries, diagnostic test results and/or laboratory results, and assesses the emergency nature of the request. Once the BPA receives the medical evidence, the BPA contacts the FO immediately, advising of the situation and providing electronic copies of the documentation obtained. The BPA does not make a decision regarding the request, but simply obtains the information and passes it on to the appropriate DO FO.
b. If the request for oxygen equipment is for a period less than 30 days (partial month), reimbursement occurs on a daily basis. The CE is to authorize units by the number of days that is being requested (e.g., The request is for dates of service 4/1/2014 – 4/20/2014. The maximum number of units authorized is 20).
c. If the request for oxygen equipment is for a period of more than 90 days and the medical evidence reasonably substantiates the chronic nature of the claimant’s accepted illness(es), the CE is to approve continuous rental, up to one year, or purchase of prescribed oxygen equipment if requested by the DME supplier.
(1) The provider will need to bill with the appropriate billing modifier to receive reimbursement. If the billing modifier is missing or invalid, the BPA will deny the bill.
(2) Prior to reimbursement being made for purchased equipment, the provider is to submit, along with the bill, proof of a transferred title to the claimant, bill of sale, and/or signed invoice by the claimant indicating receipt of the purchased equipment.
6. Authorization limitations exist, which are restrictions the CE is to adhere to when evaluating claims for Oxygen Therapy DME/Oxygen Medical Supplies. These include the following:
a. Approval for a portable oxygen system (liquid or concentrator) will only be made in combination with a stationary system or verification by the CE that the claimant already has a stationary system in his/her home.
b. Approval should not be given for more than one delivery system within a claimant’s home. A claimant is entitled to one stationary and one portable oxygen system during an authorization period unless there are extenuating circumstances justified by medical rationale.
c. Approval for a mechanical ventilator will be coordinated by the Medical Director, National Office. The DO will obtain the properly completed LMN, a copy of the hospital admission history and physical, hospital discharge summary, and a detailed report from the claimant’s treating physician containing diagnosis, prognosis, proposed treatment regime, and the qualified professional(s) who will monitor the claimant and the ventilator. Only completed information packages should be forwarded to the DEEOIC Medical Director. The information can be forwarded to the Medical Director for review and consideration through the DEEOIC bill pay mailbox.
7. Once all steps to evaluate the medical necessity of care and the appropriateness of either rental or purchase of prescribed Oxygen Therapy DME or Oxygen Medical Supplies are completed, the CE prepares a decision letter to the claimant authorizing the equipment and/or supplies. A sample approval letter can be found in Attachment 2. The CE sends a copy of the approval letter to the supplier designated by the claimant. The approval letter is to include the following information:
· Covered medical condition for which the Oxygen Therapy DME and/or Oxygen Medical Supplies is approved.
· Authorized billing code(s) relevant to the approval.
· Time period (date) during which the equipment/supplies is authorized.
· Statement advising that fees are subject to the OWCP Fee Schedule.
Upon completion of the approval, the CE sends an email to the FO, who prepares and sends a thread to the BPA, authorizing the equipment/supplies.
The CE also creates a correspondence entry in the Correspondence screen of ECS, documenting the issuance of the decision letter a approving the equipment/supplies.
8. Renewal of an existing authorization requires the claimant to obtain a LMN demonstrating a continuing need from their treating physician. The CE is to provide a copy of this evidence to their DME supplier/vendor. The requirements for approval are as previously stated. The DME supplier/vendor is to then submit the diagnostic testing (if required) to ACS for prior authorization.
9. DEEOIC will reimburse for repair, maintenance, non-routine service, and replacement of medically necessary oxygen equipment that a claimant owns. The appropriate billing code is K0740 (repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes). Repairs must be necessary to make the equipment operable. DEEOIC will not provide separate reimbursement for maintenance and service for DME covered under a manufacturer or supplier warranty agreement unless the charges are specifically excluded from the warranty. Reimbursement for repair, maintenance, non-routine service, or replacement of rented oxygen equipment is included in the monthly payment allowance and is not separately reimbursable.
All repair, maintenance, and non-routine service requests for authorization are to include supporting documentation itemizing each repair/maintenance/non-routine service. Also, the request for authorization is to indicate that the equipment is claimant owned (non-rented) and out of warranty. DEEOIC will not authorize separate travel time or equipment pick-up and/or delivery time. Repairs are reimbursed according to the OWCP Fee Schedule. DEEOIC allows up to 2 hours of service within a 120 day period. If a CE receives a repair request for more than 2 hours of service within a 120 day period, the CE forwards the request and supporting documentation to the National Office for review through the DEEOIC bill pay mailbox. The forwarded request is to list details of the documented thread, including the document control number retrieved from the Stored Image Retrieval (SIR) system and/or attached supporting documentation.
The request for authorization is to identify if a temporary replacement or “loaner” will be required. If a temporary replacement or loaner is required, DEEOIC will authorize the temporary equipment on a rental basis for up to a 1 month period, not to exceed the estimated repair time. The temporary replacement request is to include a description of the equipment being dispensed, and is to be the same type of equipment that the claimant uses to treat their illness. A new LMN is not required for the repair or temporary equipment so long as the type of equipment and/or the medical necessity is unchanged. DEEOIC will cover the cost for repair up to the OWCP Fee Schedule maximum allowable amount, not to exceed the cost of a replacement.
If a replacement is requested of previously purchased equipment approved by DEEOIC, the request is to demonstrate that the equipment was beyond repair and/or irreparably damaged and that the cost to repair the damage exceeds the cost to replace the damaged, lost or stolen equipment.
Any requests for replacement equipment that is out of warranty, not previously purchased by DEEOIC, and claimant owned for a period of 3 years or more will be reviewed and treated as a new request. The CE will determine the medical necessity and initiate a new request as outlined in this Bulletin.
10. DME suppliers may not automatically deliver additional oxygen accessories or medical supplies to claimants without a request from the claimant, an order from the treating physician, or a pre-determined schedule that is medically necessary. Accessories and supplies are comprised of, but not limited to, regulators, wheeled cart, stand, battery pack and chargers, cannula, tubing, oxygen contents, etc. For contents and content refills:
a. When authorizing the rental of a stationary gaseous system or liquid system, which requires content refills,the content refills are included in the rental price.Therefore, contents are not separately reimbursable.
b. When authorizing the rental of a portable gaseous system or portable liquid system, the CE can also approve contents for the duration of the rental. Note that one unit of contents is equal to 1 month’s supply. Therefore, when authorizing contents for the rental period, the CE should only authorize 1 unit per month.
c. When authorizing the purchase of a gaseous system or liquid system, the CE may also authorize contents for a period of 1 year. Therefore, when authorizing contents for a period of a year, the CE should only authorize 1 unit per month (e.g., 12 units = 1 year). The claimant must provide an updated LMN that supports the continued authorization of additional contents.
Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual.
RACHEL P. LEITON
Director, Division of Energy Employees
Occupational Illness Compensation
Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, and District Office Mail & File Sections