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Issue Number - Name
0102-Home Oxygen
Review Type
Complex
Claim Type
DME by Supplier; DME by Physician
Region and State
Region 5
All States
Date Approved
2018-07-10

 Description

Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary.

Affected Code(s)

E1390

Applicable Policy References

  • Social Security Act, Section 1833(e)
  • Social Security Act, Section 1861(s)(6)
  • Social Security Act, Section 1862(a)(1)(A)
  • 42 CFR Section 405.980 (b) & (c) and Section 405.986
  • 42 CFR Section 424.57(a)(12)
  • CMS Pub. 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 240.2   
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, Section 100.2.3
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 30.6, Section 130.6
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9.1
  • Local Coverage Determination, L33797, Effective Date 10/01/2015
  • Local Coverage Article, A52514, Effective Date 10/01/2015
  • CMS Policy Article, A55426, Effective date: 01/01/2017