CMS proposes oxygen change, industry worries

Friday, September 30, 2005

BALTIMORE - A proposal by CMS to expand the use of home oxygen could be a win-win for both providers and beneficiaries, but the HME industry is skeptical of the agency's motives, especially in light of recent cuts.
"Any time you open up a rule, it's open for anything," said one industry source. "Someone could say, 'We've opened it up for this,' and then say, 'We're not sure we should cover this benefit at all.'"
In mid-August, CMS began collecting public comments to determine if there's enough evidence to justify changing the current policy for beneficiaries with arterial oxygen partial pressure measurements in the range of 56-65 mmHg. The current criteria, in effect for 12 years, covers home oxygen use for patients with measurements at or below 55 mmHg or oxygen saturation at or below 88%. If certain diseases/conditions are present, an oxygen partial pressure of 56-60 mmHg or a saturation of 89% is covered.
The possibility that CMS has ulterior motives is unfounded, according to another industry source, who said those who determine coverage are focused on medical necessity and whether a rule fits within regulations. "The dollars-and-cents issue doesn't drive that discussion," he said.
If the coverage criteria is expanded, the number of oxygen users would increase by less than 5%, said Vernon Pertelle, corporate director of respiratory & HME services for Apria Healthcare. While it would have minimal impact, expanding coverage could keep beneficiaries out of hospitals, and therefore, decrease costs, he said.
"Patients who have COPD and comorbid disease, even though they may have some borderline value in which it doesn't appear that they would need oxygen therapy, we know that the disease is progressive and at some point, they have exacerbations," Pertelle said. "If we can get them on therapy sooner, we may keep them at a chronic, stable state much longer."
CMS was prompted to look into expanding coverage by a recent National Institutes of Health study, but the results of that study were inconclusive, and little other work exists on the topic, industry sources said.As a result, it's doubtful that the agency will find the "sufficient evidence" it's looking for, they said.