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March 16, 2017

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

Ankle-Foot/Knee-Ankle-Foot Orthosis LCD LinkExternal Website

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

Ankle-Foot/Knee-Ankle-Foot Orthosis Policy Article LinkExternal Website

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  • Revised: Brace Benefit explanation to remove reference to “counterforce” that is no longer applicable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

Bowel Management Devices LCD LinkExternal Website

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

Bowel Management Devices PA LinkExternal Website

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

Enteral Nutrition LCD LinkExternal Website

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

Enteral Nutrition PA LinkExternal Website

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

External Infusion Pumps LCD LinkExternal Website

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

External Infusion Pumps PA LinkExternal Website

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

Knee Orthoses LCD LinkExternal Website

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

Knee Orthoses PA LinkExternal Website

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

Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) LCD LinkExternal Website

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

Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) PA LinkExternal Website

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

Seat Lift Mechanisms LCD LinkExternal Website

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

Seat Lift Mechanisms PA LinkExternal Website

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

Spinal Orthoses: TLSO and LSO LCD LinkExternal Website

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

Spinal Orthoses: TLSO and LSO PA LinkExternal Website

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

Urological Supplies LCD LinkExternal Website

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

Urological Supplies PA LinkExternal Website

Revision Effective Date: 01/01/2017

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

  • Added: Modifiers section
  • Added: A4553 to non-covered list

Wheelchair Options/Accessories

LCD

Wheelchair Options/Accessories LCD linkExternal Website

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

Wheelchair Options/Accessories PA LinkExternal Website

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.

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