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January 12, 2023

LCD and Policy Article Revisions Summary for January 12, 2023

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 External Infusion Pumps, Intravenous Immune Globulin, Nebulizers, Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Please review the entire LCDs and related PAs for complete information.

External Infusion Pumps

LCD

External Infusion Pumps LCDExternal website

Revision Effective Date: 01/01/2023

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

  • Added: JZ modifier instructions under Drug Wastage section 

CODING INFORMATION:

  • Added: JZ modifier

HCPCS CODES:

  • Added: J1574 to group 4 codes

01/12/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

PA

External Infusion Pumps PAExternal website

Revision Effective Date: 01/01/2023

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

  • Added: Documented use of continuous glucose monitor meets glucose self-testing of at least 4 times per day within criterion IV. C. and D. of the related LCD

MODIFIERS:

  • Added: JZ modifier instructions
  • Revised: GA, GY, GZ and KX modifier instructions to include external infusion pumps, drugs and supplies

01/12/2023: 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.

Intravenous Immune Globulin

LCD

Intravenous Immune Globulin LCDExternal website

Revision Effective Date: 01/01/2023

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

  • Added: JZ modifier instructions under Drug Wastage section

CODING INFORMATION:

  • Added: JZ modifier

01/12/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

PA

Intravenous Immune Globulin PAExternal website

Revision Effective Date: 01/01/2023

MODIFIERS:

  • Added: JZ modifier instructions

01/12/2023: 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.

Nebulizers

LCD

Nebulizers LCDExternal website

Revision Effective Date: 01/01/2023

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

  • Added: JZ modifier to the DRUG WASTAGE section

SUMMARY OF EVIDENCE:

  • Removed: Summary of evidence information, due to not being applicable to the non-discretionary changes

ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):

  • Removed: Analysis of evidence information, due to not being applicable to the non-discretionary changes

CODING INFORMATION:

  • Added: JZ modifier 

BIBLIOGRAPHY:

  • Removed: Bibliography information, due to not being applicable to the non-discretionary changes

01/12/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

PA

Nebulizers PAExternal website

Revision Effective Date: 01/01/2023

MODIFIERS:

  • Added: JZ modifier instructions

01/12/2023: 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.

Oxygen and Oxygen Equipment

LCD

Oxygen and Oxygen Equipment LCDExternal website

Revision Effective Date: 01/01/2023

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

  • Removed: “For all the overnight oximetry criteria described above, the 5 minutes does not have to be continuous.” under Overnight Oximetry Studies (effective 09/27/2021)
  • Removed: “otherwise the Group III presumption of non-coverage applies” under Overnight Oximetry Studies (effective 09/27/2021)
  • Removed: “for 5 minutes total (which need not be continuous)” under criterion 4 for overnight oximetry testing for beneficiaries with OSA (effective 09/27/2021)

01/12/2023: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to updates to National Coverage Determination 240.2.

Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea

LCD

Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDExternal website

Revision Effective Date: 09/27/2021

CONCURRENT USE OF OXYGEN WITH PAP THERAPY:

  • Removed: “for 5 minutes total (which need not be continuous)” under criterion 4 for overnight oximetry testing for beneficiaries with OSA

01/12/2023 Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to updates to National Coverage Determination 240.2.

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.

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