DMERC Advisory Committee Meeting
May 4, 2000 - 5:00 p.m. – 7:00 p.m.
Present: Providers/Member
Chuck Gunther Carlos Reyes
Maureen Hanna Laura McIlvaine
Doug Thole Kim Frushon
Kimberlie Rogers Bowers Wade Hendrickson
Allen Newsom Reid Bellis
Celia Hansen Lisa Hettinger
July Runyon Douglas Wankier
Krista Rodriguez Miriam Lieber
Bill McCullough Anne Bloodsworth
Jane Thomas Len Mandaro
David Williams Richard Pozesky
Greg Lord
CIGNA Staff
Carla Cerchione Tricia Luna
Ellen Edenfield Dolly Baughman
Dina Reynolds Mary Rheinecker
Dr. Robert Hoover
HCFA Staff
Jim Underhill
The meeting began with introduction of all attendees.
Spring Seminars
The change to the Spring Seminar schedule and location was discussed. Jim Underhill clarified
the reason for the change was due to a directive issued by Nancy-Ann Min DeParle stating that
no contractor, including the DMERC, may charge for provider seminars effective June 1, 2000.
HCFA is currently reviewing contractor budgeting issues that may be impacted by this change.
CIGNA is planning to have day long seminars in 25 locations from October to December. HCFA
is also currently considering the possibility of Internet conferencing.
CIGNA clarified that there are no plans to post conference handouts on the Internet site.
Maintenance and Service Issue Update
CIGNA staff reviewed a written outline of the M&S project update prepared for this meeting.
There were 5,497 beneficiaries identified that had denied claims on the initial reports. There are
419 remaining beneficiaries that still require review by CIGNA. The review was anticipated to be
complete by May 12, 2000.
As a result of a consensus reached the previous day of DAC MS subcommittee meeting, the DAC
will be requesting additional information from other providers impacted by claim denials related to
the M&S issue. The determination to gather additional information from other Region D providers
2
was made by the subcommittee to allow further evaluation of the scope of the issue. CIGNA staff
and Jim Underhill requested that the subcommittee only gather information directly related to the
issue, and ensure unrelated items are not included in the information gathered. It was clarified by
DAC members that the MS subcommittee intends to evaluate information gathered only as a
preliminary step in assisting the subcommittee to develop a better understanding of the extent
providers within Region D have been impacted by this issue. A request was made to the DAC to
allow CIGNA and HCFA to review a draft of the form that will be sent to providers to collect the
data.
Providers were reminded that any MS claims denied prior to April 1998 cannot be related to this
issue because that is prior to the implementation of the system edit which is causing claim
denials. The Spring 2000 DMERC Dialogue includes information on ANSI message revisions that
will be used for M&S claim denials and the steps providers may take to correct claims.
A Team Questions
Several A-Teams had follow up questions after reviewing the written responses provided by
CIGNA.
Question 3: The statement regarding Proof of Delivery came from the Anti-Fraud unit. Providers
wishing to send comments related to the unique delivery requirements of external infusion and
PEN supplies may send them to the attention of Dr. Hoover or Mary Rheinecker.
Question 8: CIGNA indicates the examples submitted did not include information required by
policy. The HA0 field is 281 characters long, which may not be enough for some of the required
information. The response referred to the surgical dressing policy for clarification of information
necessary to process claims. CIGNA did not respond to examples submitted for ostomy supplies.
In a related matter: the OMB is currently reviewing The CMNs. Comments must be submitted to
the appropriate address by June 16. There is no current activity related to review of the possibility
of extending the 90-day time frame for physician signature requirement.
Question 12: CIGNA clarifies that the medical record may include all records relating to the
beneficiaries’ condition. It is not expected the exact wording referenced in the DMERC policy to
be found in the beneficiaries’ record. However, information contraindicating the medical policy
requirements should not be found. Medications and other collaborating information will be
considered during the review to determine if the medical records submitted support the medical
need.
Question 15: There should be a clear change in the medical needs of the beneficiary to begin a
new capped rental period for a particular beneficiary. The December 1997 DMERC Dialogue
includes an article titled "Starting a New Capped Rental Period" outlining the current policy.
Question 16: Providers remain concerned that the implementation of this requirement for testing
is in effect a change in the actual policy and providers were not given the opportunity for
comment.
Question 17: Dr. Hoover clarified that any change made to the estimated length of need of any
therapy automatically qualifies as a major change in the beneficiary’s condition from a clinical
perspective. Therefore, a recertification for a beneficiary with a length of need of less than lifetime
on an original CMN will require retesting.
In a related matter, Dr. Hoover clarified that no additional consideration has been given regarding
the physician evaluation to document the on-going need for oxygen therapy required to be in the
supplier file. During the last meeting, Dr. Hoover stated that he would provide additional
3
clarification as to what information should be requested by suppliers to maintain in their files to
support claim submission in the event of a post payment audit. Dr. Hoover will follow up on this
item.
Question 23: If the equipment was purchased by a local carrier prior to the transition to the
DMERCs, the provider may submit proof of payment from the previous carrier allowing the
coverage to be grandfathered by the DMERC.
Item number 6 on the agenda was tabled, as the information was not available at the meeting due
to a shipping error.
The next DAC meeting is scheduled for August 14, 2000 in the executive dining room at the
Boise office of CIGNA. A-Team meetings will not be scheduled in Boise.
Dr. Hoover made several announcements:
Dr. Doran Edwards has been hired as an associate Medical Director.
The Supplier manual is currently being revised. Anticipates the new manual to be issued in
January 2001.
Action Items
Question numbers 9 (2A), 10, 15, included on the original submission to CIGNA note that
additional follow up is required by CIGNA.
DAC Members wishing to comment on the delivery requirements for PEN items should send them
to the attention of Mary Rheinecker.
DAC Members wishing to comment on the CMN’s must submit them to HCFA at the appropriate
address by June 16, 2000.
Dr. Hoover to follow up on clarification of information needed on the physician evaluation required
to be in supplier files (Question 17).
The following information was subsequently provided by CIGNA in follow up to several issues
discussed during the meeting:
May 9, 2000
DAC QUESTIONS AND ANSWERS FOLLOW-UP
16. What is the reference for the authority to require retesting of oxygen recipients when the
length of need is less than lifetime?
Coverage Issues Manual § 60-4 states "A repeat arterial blood gas or oximetry study is
normally necessary only when evidence indicates that an oxygen recipient has undergone
a major change relevant to home use of oxygen." If upon initial certification a physician
determines that a patient will only need oxygen for a finite period of time (i.e. less than
4
lifetime), we assume there has been a major change (or he anticipated a change that
didn’t occur) in the patient’s status for the physician to consider recertifying this patient
for a subsequent period of treatment. This major change would necessitate a repeat
determination of blood oxygen saturation to ascertain if the patient needed extended
treatment.
17. What is involved in the "re-evaluation" of patients placed on oxygen (see DMERC
Dialogue article, Winter 1999, page 4)?
The DMERC does not specify what is involved in the treating physician’s re-evaluation
of a patient and their need for oxygen therapy. This is determined by the treating
physician’s clinical judgement and the medical standard-of-care for that community.
The re-evaluation may or may not involve a repeat arterial blood gas or oximetry test
unless required by Medicare coverage guidelines. The DMERC will be looking for
evidence that the physician saw the patient, considered the benefit received from the
oxygen and assessed the continued need for the oxygen therapy.
Carlo’s question on the scenario of a COPD patient, placed on a BiPAP ST (K0533) prior to
Medicare eligibility, and now wishes to continue on the K0533 once Medicare eligible. How can
this be accomplished without undergoing the trial period on a K0532 as specified in the
Respiratory Assist Device Regional Medical Review Policy?
As a general rule, patients that become eligible for Medicare benefits must meet the initial
coverage criteria outlined in the DMERC RMRPs. However, those patients on a RAD prior
to eligibility may have met the initial coverage criteria at the time they were placed on the
device but, through the use of the device, have shown improvement in their pulmonary gas
exchange such that they would no longer meet eligibility requirements.
For those patients placed on a K0533 prior to Medicare eligibility, we would consider them
similar to those placed on the device prior to the effective date of the policy who request
continued coverage. In other words, the supplier should obtain:
1. A signed and dated statement from the treating physician declaring that the patient
continues to compliantly use the device (an average of 4 hours per 24 hour period) and
that the patient is benefiting from its use, and
2. A Medicare beneficiary statement completed by the patient.
The supplier may add the ZX modifier to the claim after obtaining the above documentation.
Region D DMERC Advisory Committee
Meeting with CIGNA
Orlando, FL
October 5, 2000
Minutes
Present
DAC Members:
Len Mandaro Rick Pozesky
Syd Gubin Keith Schwartz
Martin Szmal Allen Newsome
Derek Ng Violeta Arnobit
Traci Oswalt Tim Zipp
Anne Bloodsworth Ma. Theresa Galang
Margarita Turner Rosalie Lu Weber
Michal Ragsdah Miriam Lieber
Karl Lembke Greg Lord
Vickie Houghton Deborah Davis
Velma Goertzen Judy Thompson
Val Taylor Janna Jurovich
Leslie Rigg Any Boesl
Herb Langsam Kim Frushon
Sharon Nichelson Mike Hayden
Reid Bellis Dale Cleveland
Wade Hendrickson Kimberlie Rogers-Bowers
Chuck Gunther Que Christensen
Carlos Reyes Laura McIlvaine
CIGNA Staff:
Doran Edwards, M.D. Beki Hacker
Bonitia Greffer Robert Hoover, M.D.
Mary Rheinecker Dina Reynolds
Tricia Luna Carla Cerchione
Dolly Baughman Barbara Douglas
Nicole