CQRC fears lack of template could increase denials

WASHINGTON –– The Council for Quality Respiratory Care has expressed disappointment that the recently published local coverage determination for oxygen does not call for the use of a data-driven oxygen template when documenting medical need.  

Instead, the LCD, released on Nov. 18, continues to rely on the use of patient medical records, which the CQRC says can be subjective and inconsistent and which can lead to a high rate of oxygen claim denials. 

“It is concerning that CMS missed another opportunity to streamline the claims review process by failing to adopt the use of oxygen templates with standardized clinical data elements instead of paper records,” said Crispin Teufel, chair of CQRC and CEO of Lincare. “By requiring the use of oxygen templates, CMS could protect access to a medically necessary therapy that allows individuals to remain independent in the home, reduces burdens on providers and suppliers, and cuts costs.” 

The new LCD also raises concerns, the CQRC says, that Medicare contractors could now deny patient access to supplemental home oxygen if health care providers cannot prove that “[t]he provision of oxygen and oxygen equipment in the home setting will improve the beneficiary’s condition.” 

While health care providers may seek to improve the lives of patients with certain treatments, the long history of supplemental oxygen, especially when used for patients battling chronic respiratory diseases, has shown that oxygen is needed to maintain the patient’s current status so that it does not worsen, the CQRC says. 

“This added language, unfortunately, does not recognize that each patient is unique and the important role that supplemental oxygen plays in preventing these individuals from experiencing worsening symptoms,” said Teufel.  “We hope that CMS will work with patients, providers, and suppliers to make sure that the new coverage rules do not result in patients losing access to medically necessary oxygen.”   

• Read why Crispin Teufel believes a template for oxygen is needed.