This version of the policy will become effective 12/05/2022.
The following criteria has been added to this policy as Medically Necessary:
Ostomy supplies that are prescribed by an eligible healthcare provider and supplied by an eligible ancillary provider are considered medically necessary and, therefore, covered when one of the following criteria are met:
REQUIRED DOCUMENTATION
The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
STANDARD WRITTEN ORDER REQUIREMENTSBefore submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.
PROOF OF DELIVERY REQUIREMENTSMedical record documentation must include a contemporaneously prepared delivery confirmation or member's receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.
CONSUMABLE SUPPLIES (WHEN APPLICABLE)The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual's medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.
If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.
Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2022; Final Rule. [Federal Register Web site]. 01/01/2022. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/FINAL-RULE-MASTER-LIST-of-DMEPOS-Subject-to-Frequent-Unnecessary-Utilization-2018-03-30.pdf. Accessed June 1, 2023.
Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List, 88 Fed Reg, 2546 (01/17/2023). Available at: https://public-inspection.federalregister.gov/2023-00718.pdf. Accessed June 1, 2023.
Company Benefit Contracts. Noridian Health Care Solutions, LLC. Local Coverage Determination (LCD) L33828 Ostomy Supplies. [Noridian Health Care Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33828. Accessed June 1, 2023.
Noridian Health Care Solutions, LLC. Local Coverage Article. Ostomy Supplies - Policy Article (A52487). [Noridian Health Care Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2022) https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52487. Accessed June 01, 2023.
Modifiers
This version of the policy will become effective 06/30/2023.
The Face-to-Face requirements no longer apply to code A5121 Skin Barrier; solid, 6×6 or equivalent, each.
The following criteria has been added to this policy as Medically Necessary:
