LCD and Policy Article Revisions Summary for October 9, 2025 - JD DME
LCD and Policy Article Revisions Summary for October 9, 2025
Joint DME MAC Publication
Posted October 9, 2025
Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) and Policy Articles (PAs) that have been revised and posted. The policies included are External Breast Prostheses, Oral Anticancer Drugs, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics), and Respiratory Assist Devices. Please review the entire LCDs and PAs for complete information.
External Breast Prostheses
PA
Revision Effective Date: 10/01/2025
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10-CM codes C50.A0, C50.A1 and C50.A2 to Group 1 Codes, due to ICD-10-CM code updates
10/09/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.
Oral Anticancer Drugs
PA
Revision Effective Date: 10/01/2025
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10-CM codes C50.A0, C50.A1 and C50.A2 to Groups 2, 3, 4, 6, 7, 9 Codes, due to ICD-10-CM code updates
10/09/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
PA
Revision Effective Date: 10/01/2025
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10-CM codes C50.A0, C50.A1 and C50.A2 to Group 1 Codes, due to ICD-10-CM code updates
10/09/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.
Respiratory Assist Devices
LCD
Revision Effective Date: 06/09/2025
CMS NATIONAL COVERAGE POLICY:
Added: "CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.9"
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Initial coverage of E0470 and E0471 language, by removing "severe chronic obstructive pulmonary disease (COPD)" and adding "chronic respiratory failure (CRF) consequent to chronic obstructive pulmonary disease (COPD)"
Removed: Severe COPD and related coverage criteria
Revised: Hypoventilation Syndrome coverage criterion B for E0740 and criterion B for E0471, by removing "SEVERE COPD (above)" and adding "Chronic Respiratory Failure Consequent to COPD"
Added: "Chronic Respiratory Failure Consequent to COPD" and related coverage information
Added: "The Medicare National Coverage Determinations (NCD) Manual (CMS Pub. 100-03) Chapter 1, Part 4, Section 240.9 outlines initial and continuing usage criteria for home mechanical ventilators for the treatment of CRF consequent to COPD." to the ventilators coverage information
Added: "(See §240.9 of this manual)" to quote from NCD 280.1 in section for Ventilators
Added: "and consideration of coverage criteria outlined in the Respiratory Assist Devices LCD, NCD 280.1, and/or NCD 240.9" in section for Ventilators
Revised: "CONTINUED COVERAGE CRITERIA FOR E0470 AND E0471 DEVICES BEYOND THE FIRST THREE MONTHS OF THERAPY" to "CONTINUED COVERAGE CRITERIA FOR E0470 AND E0471 DEVICES BEYOND THE FIRST THREE MONTHS OF THERAPY FOR RESTRICTIVE THORACIC DISORDERS, CSA, COMPSA, OR HYPOVENTILATION SYNDROME"
Revised: "Beneficiaries covered for the first three months of an E0470 or an E0471 device must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months." to "Beneficiaries covered for the first three months of an E0470 or an E0471 device for the treatment of restrictive thoracic disorders, CSA, CompSA, or hypoventilation syndrome must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months."
Added: "CONTINUED COVERAGE CRITERIA FOR E0470 OR E0471 DEVICES BEYOND THE FIRST SIX MONTHS FOR CRF CONSEQUENT TO COPD" and related coverage information
Added: Header to table that represents the maximum amount of accessories expected to be reasonable and necessary
Revised: "For beneficiaries who received an E0470 or E0471 device prior to enrollment in fee-for-service (FFS) Medicare and are seeking Medicare reimbursement for a rental, either to continue using the existing device or for a replacement device, coverage transition is not automatic." to "For beneficiaries who received an E0470 or E0471 device for the treatment of restrictive thoracic disorders, CSA, CompSA, or hypoventilation syndrome prior to enrollment in fee-for-service (FFS) Medicare and are seeking Medicare reimbursement for a rental, either to continue using the existing device or for a replacement device, coverage transition is not automatic." regarding beneficiaries entering Medicare
RELATED NATIONAL COVERAGE DOCUMENTS:
Added: NCD 240.9
10/09/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to NCD 240.9 Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD).
PA
Revision Effective Date: 06/09/2025
MODIFIERS:
Removed: KX modifier billing instructions regarding claims for the first through third months, the fourth month, and any month thereafter
Revised: KX modifier instruction to include use when coverage criteria is met in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD and/or in the related NCD 240.9 have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request
Removed: "In all of the situations above describing use of the KX modifier" from the GA and GZ modifiers instructions
RELATED NATIONAL COVERAGE DOCUMENTS:
Added: NCD 240.9
10/09/2025: At this time the 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.
Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.
With the update(s) listed above, Noridian would like to remind users how to find the policy that was previously effective. When billing, the supplier should follow guidance that was effective on the date of service. The below steps can be followed to find all previous policies:
- Open the currently effective policy on the Medical Coverage Database (MCD)
- Links to the MCD can be found on the Active LCDs page on the Noridian website
- There is a link at the top of the Active LCD page that goes to a full list of the LCDs or PAs, depending on which link is selected OR
- There are direct links to all LCDs under the ‘LCD ID number and Effective Date' column
- Links to the MCD can be found on the Active LCDs page on the Noridian website
- Scroll down to the bottom of the policy
- Find the section labeled Public Version(s)
- Look for the link to the policy that was effective on the dates of service in question.
- Click on hyperlink to go to the policy.
