LCD and Policy Article Revisions Summary for March 16, 2017

Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are Ankle-Foot/Knee-Ankle-Foot Orthosis, Bowel Management Devices, Enteral Nutrition, External Infusion Pumps, Knee Orthoses, Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics), Seat Lift Mechanisms, Spinal Orthoses: TLSO and LSO, Urological Supplies and Wheelchair Options/Accessories.  Please review the entire LCD and related PA for complete information.

Ankle-Foot/Knee-Ankle-Foot Orthosis

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and Directions to Standard Documentation Requirements

Added: General Requirements

HCPCS CODES:

Added: HCPCS Code A4467 & A9285

Deleted: HCPCS Code A4466

Revised: HCPCS Code L1906

ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:

Deleted: ICD-10 Diagnoses (M14.661, M14.662, M14.669) for L4631; diagnoses not pertinent to this orthosis

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and Directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Directions to Standard Documentation Requirements

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Revised: Brace Benefit explanation to remove reference to "counterforce" that is no longer applicable

Revised: Prefabricated and off-the-shelf (OTS) "minimal self-adjustment" regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment

Deleted: A4466

Added: A4467

Added: Instructions for A9285

Added: Policy specific documentation requirements from LCD

CODING GUIDELINES:

Removed: Reference to classification algorithm summary

Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of "minimal self-adjustment"

Added: Section on coding of elastic and similar materials

Deleted: A4466

Added: A4467

Added A9285

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements Language Article

 

Bowel Management Devices

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and directions to Standard Documentation Requirements

Added: General Requirements

Added: Denial language for A4553

HCPCS CODES:

Added: HCPCS Code A4553

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Direction to Standard Documentation Requirements

Deleted: Sources of Information

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Added: HCPCS Codes A4553 to Statutorily excluded from coverage list

Added: Policy Specific Documentation Requirements

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements Language Article

 

Enteral Nutrition

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and directions to Standard Documentation Requirements

Removed: HCPCS Code B9000 from equipment and supplies documentation requirements

Added: Unbundling instructions for enteral supply allowances.

Added: General Requirements

Revised: Refill Requirements

Removed: HCPCS Code B9000 from documentation requirements

HCPCS MODIFIERS:

Deleted: Code B9000

Revised: Code narrative for HCPCS B9002

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Direction to Standard Documentation Requirements

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Added: Supply payment allowance for HCPCS B4034 – B4036

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: DIF requirements

Updated: Recertification DIF to revised DIF

CODING GUIDELINES:

Revised: Coding guidelines of items included in the feeding supply allowance

Added: Guidelines for blenderized and calorically dense formulations

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements Language Article

 

External Infusion Pumps

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and Directions to Standard Documentation Requirements

Added: Billing instructions for A4224 and A4225

Added: General Requirements

Revised: Refill Requirements

Revised: Drug Waste verbiage

HCPCS MODIFIERS:

Added: Codes A4224 and A4225

Revised: Code narratives for HCPCS A4221, J7340 and K0552

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and Directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Direction to Standard Documentation Requirements

Removed: Information from Miscellaneous

Removed: PIM citation from under Appendices

SOURCES OF INFORMATION AND BASIS FOR DECISION:

Removed: Links

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Replaced: A4221 with A4224 when using catheter insertion devices

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: 42 CFR 410.38(g), DIF and Modifiers requirements

CODING GUIDELINES:

Added: Billing instructions for A4224 and A4225

RELATED LOCAL COVERAGE DOCUMENTS:

Added: The LCD-related Standard Documentation Requirements Language Article

 

Knee Orthoses

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and directions to Standard Documentation Requirements

Deleted: K0901 and K0902

Added: L1851 and L1852

Added: General Requirements

HCPCS CODES:

Deleted: A4466, K0901 and K0902

Added: A4467, L1851 and L1852

ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:

Deleted: K0901 and K0902 from Group 4 Paragraph

Added: L1851 and L1852 to Group 4 Paragraph

Added: ICD-10 Codes M21.861 and M21.862 to Group 5 –Effective 10/01/2015

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Directions to Standard Documentation Requirements

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Revised: Brace Benefit explanation to remove reference to "counterforce" that is no longer applicable

Revised: Prefabricated and off-the-shelf (OTS) "minimal self-adjustment" regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment

Deleted: A4466

Added: A4467

Deleted: K0901 & K0902 from the Reasonable Useful Lifetime table

Added: L1851 & L1852 to the Reasonable Useful Lifetime table

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: Modifiers

CODING GUIDELINES:

Removed: Reference to classification algorithm summary

Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of "minimal self-adjustment"

Added: Section on coding of elastic and similar materials

Deleted: A4466

Deleted: K0901 & K0902

Added: A4467

Added: L1851

Added: L1852

Deleted: K0901 & K0902 from the Not Separately Payable table

Added: L1851 & L1852 to the Not Separately Payable table

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements Language Article

 

Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and directions to Standard Documentation Requirements

Added: General Requirements

Revised: Refill Requirements

HCPCS Code:

Added: J8670

Deleted: Q9981

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Direction to Standard Documentation Requirements

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: Standard Documentation Language article

Retired bulletin article titled: Coverage and Coding - New Oral Antiemetic Drug Varubi®- Revised- Effective Date July 1, 2016

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Added: HCPCS J8670 for billing Rolapitant effective on or after 01/01/2017

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: Billing instructions and Modifiers section

CODING GUIDELINES:

Added: HCPCS J8670 for billing Rolapitant effective on or after 01/01/2017

RELATED LOCAL COVERAGE DOCUMENTS:

Added: The LCD-related Standard Documentation Requirements Language Article

 

Seat Lift Mechanisms

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and directions to Standard Documentation Requirements

Added: General Requirements

HCPCS CODES:

Deleted: Code E0628

Revised: Code narratives for E0627 and E0629

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Directions to Standard Documentation Requirements

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: 42 CFR 410.38(g) and Certificate of Medical Necessity requirements

CODING GUIDELINES:

Removed: HCPCS Code E0628

Revised: HCPCS code narratives for Codes E0627 and E0629

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements Language Article

 

Spinal Orthoses: TLSO and LSO

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and Directions to Standard Documentation Requirements

Added: General Requirements

HCPCS CODES:

Added: HCPCS Code A4467

Deleted: HCPCS Code A4466

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and Directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Directions to Standard Documentation Requirements

Removed: Supplier Manual reference from Miscellaneous section

Removed: Information under Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Revised: Brace Benefit explanation to remove reference to "counterforce" that is no longer applicable

Revised: Prefabricated and OTS "minimal self-adjustment" regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment

Deleted: A4466

Added: A4467

Added: Policy specific documentation requirements from LCD

CODING GUIDELINES:

Removed: Reference to classification algorithm summary

Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of "minimal self-adjustment"

Added: Section on coding of elastic and similar materials

Deleted: A4466

Added: A4467

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements Language Article

 

Urological Supplies

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and directions to Standard Documentation Requirements

Added: General Requirements

Revised: Refill Requirements

HCPCS Code:

Added: A4553

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Direction to Standard Documentation Requirements

Removed: Information under Miscellaneous and Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: Modifiers section

Added: A4553 to non-covered list

 

Wheelchair Options/Accessories

LCD

Revision Effective Date: 01/01/2017

COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:

Removed: Standard Documentation Language

Added: New reference language and Directions to Standard Documentation Requirements

Added: General Requirements

HCPCS CODES:

Revised: Descriptor changed in Group 1 - K0015, K0019; Group 2 - E0995, K0037, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052; Group 4 -E0967, E2206, E2220, E2221, E2222, E2224, K0069, K0070, K0071, K0072, K0077; Group 8 - K0098

DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: General Documentation Requirements

Added: New reference language and Directions to Standard Documentation Requirements

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Removed: Standard Documentation Language

Added: Direction to Standard Documentation Requirements

Removed: Information under Miscellaneous

Removed: Information under Appendices

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Policy Article

Revision Effective Date: 01/01/2017

NON MEDICAL NECESSITY PAYMENT RULES:

Added: Coverage rule for E0950

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Added: 42 CFR 410.38(g) and Modifier requirements

Added: Instructions for replacement codes

RELATED LOCAL COVERAGE DOCUMENTS:

Added: LCD-related Standard Documentation Requirements article

Note: The information contained in this article is only a summary of revisions to the LCDs and Policy Articles.  For complete information on any topic, you must review the LCDs and/or Policy Articles.

Last Updated Wed, 15 Mar 2017 10:20:42 +0000