FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

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EEOICPA Tr. NO. 17-04 i 

January 2017 

TABLE OF CONTENTS 

Paragraph and Subject Date Trans. No. 

Chapter 3-0300 Ancillary Medical Services and Related Expenses 

 Table of Contents. . . . . . . . . 01-17 17-04 

 1 Purpose and Scope. . . . . . . . . 01-17 17-04

 2 Requests for Ancillary Medical 

 Services and Related Expenses. 01-17 17-04 

 3 Durable Medical Equipment. . . . . 01-17 17-04 

 4 Oxygen Therapy DME and 

 Oxygen Medical Supplies. . . . . 01-17 17-04 

 5 Massage Therapy and Acupuncture 

 Treatment. . . . . . . . . . . . 01-17 17-04 

 6 Chiropractic Services. . . . . . . 01-17 17-04 

 7 Pulmonary Rehabilitation . . . . . 01-17 17-04 

 8 Hearing Aids . . . . . . . . . . . 01-17 17-04 

 9 Organ Transplants. . . . . . . . . 01-17 17-04 

 10 Mental or Psychiatric 

 Illness Treatment. . . . . . . . 01-17 17-04 

 11 Experimental Treatment . . . . . . 01-17 17-04 

 12 Sun Protective Clothing. . . . . . 01-17 17-04 

 13 Vehicle Modifications 

 and Purchases. . . . . . . . . . 01-17 17-04 

 14 Housing Modifications. . . . . . . 01-17 17-04 

 15 Health Facility Membership 

 and Spa Membership . . . . . . . 01-17 17-04 

 16 Medical Alert Systems. . . . . . . 01-17 17-04 

 17 Medical Expense Reimbursement 

 for Extended Travel. . . . . . . 01-17 17-04 

 18 Ancillary Services or Expense 

 Authorization RD . . . . . . . . 01-17 17-04 

Exhibits 

1 Ancillary Medical Services 

Development Letter. . . . . . . . 01-17 17-04 

2 Ancillary Medical Services 

 Authorization Letter. . . . . . . 01-17 17-04 

3 Development Letter(DME/Oxygen 

 Treatment Therapy/ 

 Oxygen Medical Supplies). . . . 01-17 17-04 

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EEOICPA Tr. NO. 17-04 ii 

January 2017 

 

4 Authorization Letter (DME/ 

 Oxygen Treatment Therapy/ 

 Oxygen Medical Supplies. . . . . . 01-17 17-04 

5 Oxygen Delivery Systems. . . . . . . 01-17 17-04 

6 Sample Home Modification Letter. . . 01-17 17-04 

7 Travel Authorization Letter. . . . . 01-17 17-04 

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1. Purpose and Scope. This chapter includes the 

procedures that the Division of Energy Employees 

Occupational Illness Compensation (DEEOIC) claims staff use 

in evaluating and approving requests for ancillary medical 

services, durable medical equipment (DME) and supplies, and 

related expenses.

 

2. Requests for Ancillary Medical Services and Related 

Expenses. This chapter provides further guidance relating 

to the review process for requests pertaining to a wide 

variety of ancillary services and related expenses. A 

claimant, authorized representative (AR), treating 

physician, or a provider may request the services and 

related expenses described in this chapter. Requestors are 

to make their claims by sending them to the DEEOIC Bill 

Processing Agent (BPA) via fax, mail, or electronic 

submission. The assigned Claims Examiner (CE), or a Final 

Adjudication Branch (FAB) staff person, who receive 

requests through the OWCP Imaging System (OIS), forwards 

them to the BPA. 

a. The BPA creates an electronic record of the 

request and initiates a thread to the Fiscal Officer 

(FO) at the district office where the claimant’s case 

file resides. The thread from the BPA advises the FO 

of a pending request for authorization of services. 

For DME or supplies requests, the thread details will 

include a statement indicating if any requested DME or 

 supplies are subject to the Office of Workers’ 

 Compensation Programs (OWCP) Medical Fee Schedule. 

b. The requestor must submit a Letter of Medical 

Necessity (LMN), (or an updated LMN in the event that 

reauthorization for an additional period of time is 

being requested). A LMN is the written explanation 

from the treating physician describing the medical 

need to assist the claimant in the treatment, care, or 

relief of their accepted work-related illness(s). To 

ensure that the physician’s opinion derives from a 

recent physical assessment of the claimant’s medical 

status, the physician is to document that a face-toface visit/evaluation occurred between the claimant 

and the prescribing physician, within six months prior 

to the date that the physician orders the service. The 

LMN must clearly identify the type of ancillary 

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medical service sought, explain why it is medically 

necessary for the accepted condition, and specify the 

duration of use. The requestor is to submit any 

supporting documentation substantiating the medical 

need for the requested service (i.e.; medical reports, 

prescriptions, therapy reports, diagnostic reports). 

c. Requests submitted for authorization are to 

include the following: 

(1) Claimant information such as name, case file 

number, date of birth, and telephone number. 

 

(2) Provider, supplier, or requestor information 

including name, provider address, provider 

number, Tax ID number, National Provider Number 

(NPI), telephone number, and fax number. 

 

(3) Prescribing/treating physician contact 

information including name, address, telephone 

number, and fax number. 

 

(4) The billing code(s) such as HCPCS and/or 

Current Procedural Terminology (CPT), code 

modifier(s), total cost, begin date, and end 

date. 

(5) Diagnosis code(s) for the condition(s) for 

which the item(s) is being prescribed. 

(6) In addition, requests submitted for 

authorization for DME or oxygen therapy DME and 

oxygen medical supplies are to include the 

following: 

(i) Supporting documentation that provides 

the need for DME and/or Medical Supplies 

(i.e.; prescription, narrative LMN, 

supporting medical documentation). 

(ii) Equipment billing code(s) (HCPCS/CPT), 

modifier(s), quantity, purchase price and 

rental price, total cost, begin date, end 

date, duration of use and frequency. 

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(iii) The provider will need to bill with 

the appropriate billing modifier to receive 

reimbursement. If the billing modifier is 

missing or invalid, the BPA will deny the 

bill. 

(iv) Prior to payment being made for 

purchased equipment, the provider is to 

submit, along with the bill, proof of a 

transferred title to the claimant, bill of 

sale, and/or signed invoice by the claimant 

indicating receipt of the purchased 

equipment. 

d. Upon receipt of an authorization request, not 

accompanied by appropriate medical evidence, the CE 

begins development. 

(1) The CE sends a development letter to the 

claimant advising that he or she has received a 

request, but without the required supporting 

documentation. The CE’s development letter to the 

claimant must include a clear description of the 

medical documentation needed to support the 

request, and grant the claimant 30 calendar days 

to provide the information. The CE also notifies 

the claimant that a lack of response or 

submission of insufficient evidence will result 

in a denial of the request. Exhibit 1 is a sample 

development letter for ancillary medical services 

and Exhibit 3 is a sample letter for DME / Oxygen 

therapy and related medical supplies. The CE 

updates the correspondence section of ECS to 

record the issuance of the development letter, 

once mailed. 

(2) If the CE receives the appropriate 

medical evidence within the 30-day development 

period, the CE prepares an authorization letter 

to the claimant (Exhibit 2 for ancillary medical 

services or Exhibit 4 for DME / Oxygen therapy and 

related supplies sample letters). 

(3) In situations 

where the treating physician 

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does not respond or does not provide clarifying 

medical rationale to support the request, the CE 

may refer the matter to a Contract Medical 

Consultant (CMC) for review. 

e. Communicating the decision to the requestor: Upon 

completion of all appropriate development steps for 

the requested services, and upon review of all 

evidence submitted, the CE communicates a decision to 

approve or deny such services to the requestor. The CE 

sends an e-mail to the FO, who prepares and sends a 

thread to the BPA, authorizing or denying the claimed 

medical services or related expenses. The CE also 

creates a correspondence entry in the Correspondence 

screen of the Energy Compensation System (ECS), 

documenting the decision. 

f. Communicating the decision to the claimant: When 

the CE receives a request for authorization, 

accompanied by appropriate medical evidence, the CE 

prepares an authorization letter to the claimant, 

approving the requested services (Exhibit 2 – Sample 

Letter for approving ancillary medical services or 

Exhibit 4 – Sample letter for approving DME, Oxygen 

Therapy and related supplies). The CE sends a copy of 

the letter to the supplier/vendor designated by the 

claimant. The approval letter is to include the 

following information: 

(1) Covered medical condition(s) for which the 

DME is approved, massage therapy is prescribed, 

or the condition to be treated with acupuncture. 

 (2) Authorized billing code(s) relevant to the 

 approval. 

(3) Time period (To and From dates) during which 

the DME rental/purchase is authorized and/or 

number of frequency and visits approved for 

massage therapy and acupuncture therapy (i.e.; 

two visits per week for eight weeks). 

 (4) Statement advising that fees are subject to 

 the OWCP Medical Fee Schedule. 

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 (5) Statement advising that if the rental is 

converted to a purchase, rental expenses incurred 

and paid will be deducted from the purchase price 

and only the difference will be reimbursed. 

3. Durable Medical Equipment (DME). A physician must 

prescribe all DME, supplies, and custom devices. DME serve 

a medical purpose and can withstand repeated use (e.g.; 

hospital beds, walkers, and wheel chairs, etc.). 

a. A CE must review all requests for the rental 

and/or purchase of DME to determine their medical 

necessity. Requests for DME rental or purchase require 

pre-authorization.

b. In instances where DME, supplies, and custom 

devices have a total purchase price greater than $500 

and the OWCP Medical Fee Schedule does not apply, the 

CE is to undertake development with the claimant. 

(1) The claimant must submit two estimates from 

two different DME suppliers to include the 

supplier name and supplier contact information. 

These estimates must be for exactly the same type 

of DME, and/or supplies. 

(2) Each potential supplier must submit a signed 

statement describing the DME, supplies, or 

unadorned item meeting the treating physician’s 

specifications, and a breakdown of all costs 

including delivery and installation, and the 

current Healthcare Common Procedure Code System 

(HCPCS) code for each DME, supply and/or item 

needed. 

c. Where the purchase of DME, supplies or custom 

devices are less than $500 or when the OWCP medical 

fee schedule applies, the CE may approve the purchase 

request, after appropriate medical evidence is 

received, without obtaining cost estimates. 

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authorization for rental rather than purchase. In most 

situations, DME rental is the preferred choice. The CE 

may authorize the rental of DME for up to six months. 

 

 (1) The CE should review the LMN and the 

provider-submitted rental proposal to ensure that 

the DME will satisfy the needs of the claimant as 

outlined by his or her physician. If the CE 

determines that the rental meets the medical 

requirements of the physician, he or she is to 

grant authorization for DME rental for six months 

(or less depending on the need of the claimant). 

The CE mails a letter of authorization to the 

claimant, along with a copy to the chosen DME 

provider. Additional details on the DME 

authorization are provided later in this section. 

 (2) For each DME rental authorization that may 

extend beyond the initial authorization period, 

the CE is to enter a reminder in ECS that 

reauthorization occurs at a six-month interval. 

The CE must set the reminder to occur 60 days 

prior to the expiration date of authorized DME 

rental. 

f. In certain situations, the CE may authorize the 

purchase of DME or supplies. When considering the 

purchase of DME, the CE is to use discretion to ensure 

that any authorization granted for the purchase of any 

DME satisfies the medical needs of the claimant. The 

CE should not authorize a request for DME based on 

convenience, comfort, or other non-medical reasons. 

DME purchases can only be approved if the CE is able 

to obtain such an option from an enrolled provider. 

(1) Items that should not be rented but 

considered for purchase include medical/surgical 

supplies (i.e.; ostomy, incontinence, dialysis, 

wound care), canes, crutches, and commodes. 

(2) The CE may evaluate a DME purchase, when the 

purchase price of such equipment or item is more 

cost effective than the rental price. For 

example, if the price of renting a standard 

wheelchair is more than the cost to purchase it, 

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the CE should approve the purchase of the 

wheelchair rather than renting it. 

(3) When reauthorizing rentals, the CE must 

consider whether the cost to purchase the 

equipment, minus the rental amount paid, is less 

than the total cost to authorize another six 

months of rental. If agreeable with the claimant 

and the DME provider, the CE may authorize the 

purchase of such equipment. Otherwise, the CE is 

to continue to review the claim as a DME rental. 

(i) Situations may arise when the CE 

previously authorized the rental of a DME, 

then subsequently receives a request for 

authorization to purchase that same item. 

Under these circumstances, it may become 

necessary to convert the rental to a 

purchase. If the CE receives a request for a 

purchase, the rental charges were paid for 

the same DME with no break in service 

between the rental period and the approved 

purchase period and the provider who billed 

for the rental is the same as the provider 

now requesting the purchase, the CE must 

request that the provider deduct the rental 

charges previously paid from the cost of the 

item being purchased. DEEOIC reimburses all 

post-purchase requests (from a rental) in 

accordance with the applicable OWCP Medical 

Fee Schedule amount. 

g. Repair/Maintenance Cost. The CE must authorize 

the cost for modifications and maintenance to DME 

equipment when evidence is received validating the 

need for changes/repair/maintenance of previously 

approved DME. 

 h. Replacement. A new request must be submitted if a 

 claimant requires a replacement of previously 

 purchased equipment approved by DEEOIC for purchase. 

 The CE must approve DME for replacement if the 

 equipment is three years or older, inoperable and 

 beyond repair, or the request demonstrates repair 

costs that exceed the cost to replace the equipment, 

and that the equipment is no longer covered by 

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warranty, or if the equipment is lost or stolen. In 

the event the equipment is stolen, the claimant must 

furnish a police report documenting the incident. The 

CE can consult with the national office Medical Bill 

Processing Unit (MBPU) for situations involving unique 

or unusual circumstance. 

i. DME add-ons or Upgrades. DEEIOC will consider 

approval for DME add-ons or upgrades where the 

evidence substantiates the medical need for the 

enhancement. Add-ons and/or upgrades are not approved 

for the claimant’s convenience or where such 

enhancements do not significantly improved DME 

functionality. 

j. Emergency situations. The CE may authorize the 

rental of DME for a preliminary 30-day period while 

additional development is undertaken. 

(1) If medical documentation from the treating 

physician supports the need for immediate DME 

authorization, the CE provides approval for 30 

days pending additional development. 

(2) The CE sends a letter to the treating 

physician (with a copy to the claimant) 

requesting necessary evidence to substantiate 

that the DME is medically necessary. This should 

occur within the preliminary 30-day authorization 

period. The CE may grant extensions in increments 

of 30 days, not to exceed a total of six months, 

while awaiting necessary medical evidence. 

k. When the CE receives a request for authorization 

of DME and appropriate medical evidence does not 

accompany the request, the CE begins development. 

Refer to Section 2(d) for further guidelines to begin 

development. 

l. When the CE receives a request for authorization 

of DME, accompanied by appropriate medical evidence, 

the CE prepares a decision letter to the claimant 

authorizing the DME. Refer to Section 2(e-f) for 

further guidelines in communicating a decision. 

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4. Oxygen Therapy DME and Oxygen Medical Supplies. This 

section provides procedural guidelines the CE follows when 

reviewing and authorizing requests for the rental or 

purchase of Oxygen Therapy DME or Oxygen Medical Supplies. 

a. Physicians prescribe Oxygen Therapy DME and 

Oxygen Medical Supplies to treat patients diagnosed 

with different forms of pulmonary disease. Some 

examples of Oxygen Therapy DME and Oxygen Medical 

Supplies include stationary and portable oxygen 

concentrators, gaseous and liquid oxygen delivery 

systems, cannulas, tubing, regulators, etc. (Exhibit 5 

provides definitions and describes the functions of 

some of the more commonly prescribed oxygen DME.) The 

CE reviews requests for the rental and/or purchase of 

Oxygen Therapy DME and Oxygen Medical Supplies to 

validate their medical necessity. Refer to Section 

2(c) to see what is required for authorization. 

b. Upon receipt of the request for rental or 

purchase of Oxygen Therapy DME and/or Oxygen Medical 

Supplies, the CE evaluates the medical evidence to 

determine if there is sufficient justification to 

authorize the request as medically necessary for the 

treatment or care of an accepted condition. In 

addition to the guidelines already described in 

Section 2(g), the claimant must include the following:

 

(1) Diagnostic testing that supports the 

physician’s reasons for prescribing Oxygen 

Therapy DME or Oxygen Medical Supplies, and 

identifies clear, objective pulmonary deficits 

including results from an arterial blood gas 

(ABG) and/or resting/exercise spirometry test, 

and/or nocturnal oximetry studies. The results 

are to identify the conditions under which the 

test(s)/studies were performed; (i.e.; during 

exercise, at rest, or during sleep). The test(s) 

are to be performed by a qualified medical 

professional, and originate from a qualified 

source such as a laboratory, diagnostic testing 

facility, hospital, physician’s office or clinic. 

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c. Additional Information. If the CE determines the 

evidence is deficient, for example, the physician has 

not provided a clear description of the needed Oxygen 

Therapy DME and/or Oxygen Medical Supplies, or has not 

provided information on the duration or use of the 

prescribed equipment, the CE initiates development. 

Refer to Section 2(b) for guidance on development. 

 

d. Upon receipt of appropriate evidence establishing 

the medical necessity for Oxygen Therapy DME and/or 

Oxygen Medical Supplies, the CE proceeds to assess 

whether it is appropriate to authorize a short-term 

rental, continuous rental, or a purchase of the 

requested DME. 

 

(1) For authorization of equipment rentals, the 

DEEOIC will reimburse monthly charges for the 

approved equipment. A rental period for oxygen 

equipment is one month (30 or 31 days) and is 

equivalent to one unit of service. When oxygen 

equipment is purchased, the DEEOIC will reimburse 

for a one-time charge, not to exceed the total 

allowable amount as set forth in the OWCP Medical 

Fee Schedule. 

(2) If the request for oxygen equipment is for a 

period of 90 days or less, oxygen equipment shall 

be reimbursed on a monthly rental basis according 

to the OWCP Medical Fee Schedule. The rental 

reimbursement amount includes delivery, set-up, 

education, and training for the claimant, and is 

not separately reimbursable. 

(3) If the request for oxygen equipment is for a 

period of less than 30 days (partial month), 

reimbursement occurs on a daily basis. The CE is 

to authorize units by the number of days that is 

being requested (e.g.; the request is for dates 

of service 4/1/2016 – 4/20/2016. The maximum 

number of units authorized is 20). 

(4) If the request for oxygen equipment is for a 

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period of more than 90 days, the CE is to approve 

continuous rental, up to one year, or purchase of 

prescribed oxygen equipment if requested by the 

DME supplier. 

(5) In emergency or urgent situations (such as 

the claimant being discharged from the hospital 

to home with urgent oxygen needs), the CE can 

authorize up to a 30-day rental period for oxygen 

equipment, while additional development is 

undertaken. The CE may grant additional 

extensions of 30-day increments during 

development, not to exceed a six month period. 

 e. Authorization Limitations. The CE is to adhere 

 to the following restrictions when evaluating claims 

 for Oxygen Therapy DME and/or Oxygen Medical Supplies. 

(1) Approval for a portable oxygen system 

(liquid or concentrator) will only be made in 

combination with a request for a stationary 

system, or after verification by the CE that the 

claimant already has a stationary system in the 

home. 

(2) Approval should not be given for more than 

one delivery system within a claimant’s home. A 

claimant is entitled to one stationary and one 

portable oxygen system during an authorization 

period unless there are extenuating circumstances 

justified by medical rationale (LMN). 

(3) Approval for a mechanical ventilator will be 

coordinated by the DEEOIC Medical Director. The 

DO will obtain the properly completed LMN, a copy 

of the hospital admission history and physical, 

hospital discharge summary, and a detailed report 

from the claimant’s treating physician containing 

diagnosis, prognosis, proposed treatment regime, 

and the qualified professional(s) who will 

monitor the claimant and the ventilator. Once the 

completed information package is obtained, the CE 

forwards it to the DEEOIC Medical Director for 

review and consideration. The CE addresses any 

such requests to the DEEOIC Medical Director, 

through the DEEOIC Bill Pay Mailbox. Further 

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information regarding this mailbox is discussed 

in PM 2-0200.

f. Upon the approval of either rental or purchase of 

the prescribed Oxygen Therapy DME and/or Oxygen 

Medical Supplies, the CE prepares a decision letter to 

the claimant and the requestor as outlined above in 

Section 2, e-f, authorizing the equipment 

and/or supplies. Renewal of an existing authorization 

requires the claimant to obtain a LMN demonstrating a 

continuing need for the oxygen therapy DME or oxygen 

medical supplies. 

g. DEEOIC will reimburse for repair, maintenance, 

non-routine service, modifications necessary to make 

the equipment operable, and replacement of medically 

necessary oxygen equipment that a claimant owns. 

DEEOIC will not provide separate reimbursement for 

maintenance and service for DME covered under a 

manufacturer or supplier warranty agreement unless the 

charges are excluded from the warranty. Reimbursement 

for repair, maintenance, non-routine service, or 

replacement of rented oxygen equipment is included in 

the monthly payment allowance and is not separately 

reimbursable. 

h. All repair, maintenance, and non-routine service 

requests for authorization must include the following: 

(1) Supporting documentation itemizing each 

repair/maintenance/non-routine service. 

(2) The request for authorization is to indicate 

that the equipment is claimant-owned (non-rented) 

and out of warranty. 

(3) DEEOIC will not authorize separate travel 

time or equipment pick-up and/or delivery time. 

Services are reimbursed according to the OWCP 

Medical Fee Schedule. 

(4) DEEOIC allows up to two hours of service 

within a 120-day period. If a CE receives a 

repair request for more than two hours of service 

within a 120-day period, the CE forwards the 

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request and supporting documentation to the 

National Office for review through the DEEOIC 

bill pay mailbox. The CE is to list details of 

the documented thread, including the document 

control number retrieved from the Xerox 

Transaction Content Management (XTCM) stored 

image retrieval system and/or attached supporting 

documentation. 

(5) The request for authorization is to indicate 

whether a temporary replacement or “loaner” will 

be required. If a temporary replacement or loaner 

is required, DEEOIC will authorize the temporary 

equipment on a rental basis for up to a one-month 

period, not to exceed the estimated repair time. 

 (i) The temporary replacement request is to 

 include a description of the equipment being 

 dispensed, and is to be the same type of 

 equipment that the claimant uses to treat 

 their illness. 

 (ii) A new LMN is not required for the 

 repair or temporary equipment as long as the 

 type of equipment and/or the medical 

 necessity is unchanged. DEEOIC will cover 

 the cost for repair up to the OWCP Medical 

 Fee Schedule maximum allowable amount, not 

 to exceed the cost of a replacement. 

(6) A new request must be submitted if a 

claimant requires a replacement of previously 

purchased equipment approved by DEEOIC for 

purchase. The CE must approve DME for replacement 

if the equipment is three years or older, or it 

is inoperable and beyond repair, or the request 

demonstrates repair costs that exceed the cost to 

replace the equipment, and that the equipment is 

no longer covered by warranty, or if the 

equipment is lost or stolen. In the event the 

equipment is stolen, the claimant must furnish a 

police report documenting the incident. The CE 

can consult with the national office Medical Bill 

processing Unit (MBPU) for situations involving 

unique or unusual circumstance. 

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i. DME suppliers may not automatically deliver 

additional oxygen accessories or medical supplies to 

claimants without a request from the claimant, an 

order from the treating physician, or a pre-determined 

schedule that is medically necessary. Accessories and 

supplies are comprised of, but not limited to, 

regulators, wheeled carts, stands, battery packs and 

chargers, cannulas, tubing, oxygen contents, etc. When 

authorizing contents and content refills: 

(1) For the Rental of a Stationary Gaseous 

System/Liquid: The content refills are included 

in the rental price. Therefore, contents are not 

separately reimbursable. 

(2) For the Rental of a Portable Gaseous 

System/Liquid: 

The CE can approve contents for the duration of 

the rental of a portable gaseous system or 

portable liquid system. One unit of contents is 

equal to one month’s supply. Therefore, when 

authorizing contents for the rental period of a 

portable gaseous system, the CE should only 

authorize one unit per month. 

(3) For the Purchase of a Gaseous System/Liquid: 

Purchased systems do not include contents, thus, 

when authorizing the purchase of a gaseous system 

or liquid system the CE authorizes contents for a 

period of one year. Contents are authorized based 

on one unit per month (i.e.; 12 units = one 

year). The claimant must provide an updated LMN 

that supports the need for continued 

authorization of additional contents. 

5. Massage Therapy/Acupuncture Treatments. This section 

provides procedural guidance with regard to the review and 

development process leading up to an authorization or 

denial of a request for Massage Therapy and/or Acupuncture 

Treatments. 

a. The treating physician must prescribe massage 

therapy and/or acupuncture treatment only for the 

treatment or care of the claimant’s covered medical 

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condition(s). Along with the signed prescription from 

the treating physician, the requestor must submit a 

LMN to reflect that an initial face-to-face visit was 

held with the claimant. Face-to-face visits are only 

required for the initial pre-authorization 

request. The narrative of the LMN should describe the 

unique physical and therapeutic benefits that the 

claimant will derive from massage therapy or 

acupuncture treatment, and specify the frequency and 

duration of care to be provided in allotments of time 

(e.g.; twice a week for eight weeks). 

 

b. When the CE receives a massage therapy and/or 

acupuncture treatment request unaccompanied by an LMN, 

the CE begins development. Refer to Section 2(d) for 

further guidelines to begin development. 

c. If the CE receives the appropriate medical 

evidence within the 30-day development period, the CE 

prepares a letter to the claimant authorizing massage 

therapy and/or acupuncture treatment. Refer to Section 

2(e-f) for further guidelines in communicating the 

approval. 

d. The initial authorization period may be fewer 

than, but should not exceed eight weeks, and the CE 

may approve up to two visits per week, for 16 visits 

during the initial authorization period. Each visit is 

equal to a maximum of 1.5 hours. Reauthorization, 

including obtaining updated medical evidence is 

required for any request for additional massage 

therapy or acupuncture treatment after the initial 

eight-week period. The CE may not authorize more than 

60 massage therapy and/or acupuncture treatment visits 

per calendar year. 

e. If, at the end of the initial eight-week 

authorization period, the CE receives a new request 

for additional massage therapy and/or acupuncture 

treatment, the CE must conduct a new evaluation of the 

medical necessity for continuation of care. If the 

request is appropriate (updated medical documentation 

adequately explains the medical necessity for 

continuing massage therapy and/or acupuncture 

treatment), the CE grants authorization for the 

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extension of care within the authorization parameters 

of no more than two visits per week and a maximum of 

60 visits per year. 

f. Massage therapists and/or acupuncture providers, 

must hold a valid massage therapist’s license or 

certification in the state where services are 

rendered. 

g. Massage therapy and/or acupuncture treatment 

services must be conducted in an appropriate setting 

(i.e.; medical clinic, medical office) and should be 

billed daily (i.e.; one date of service per OWCP-1500 

line). 

(1) The service provider must submit medical 

notes to the DEEOIC’s BPA, along with their bill, 

describing the particular therapeutic care 

provided during each visit with the claimant. The 

notes should describe the effect of the massage 

therapy, including any specific improvements in 

functionality or in achieving relief from the 

symptoms of a compensable illness. The BPA then 

forwards the medical notes to the district office 

for review. 

(2) The OWCP Medical Fee Schedule does not 

provide a separate allowance for massage therapy 

and/or acupuncture supplies (i.e.; tables, 

equipment). The cost of supplies is factored into 

the fee schedule amount. 

h. If the CE receives a request for in-home massage 

therapy and/or acupuncture treatment, the claimant 

must be homebound in order to receive authorization 

for such services. Medical evidence from the treating 

physician must demonstrate that the claimant is 

medically unable to travel to obtain massage therapy 

and/or acupuncture treatment. Once the CE receives 

convincing evidence that the claimant is not able to 

travel for care, and sufficient documentation exists 

regarding the medical necessity for care, the CE may 

authorize in-home massage therapy and/or acupuncture 

treatment.

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i. Massage therapy and/or acupuncture treatment is 

not restricted by medical diagnosis or condition, but 

is not appropriate when prescribed solely for 

prevention of future injury, recreation (spa therapy), 

and/or stress reduction. 

6. Chiropractic Services. The CE may authorize 

chiropractic services limited to treatment for correction 

of spinal subluxation, along with the tests performed or 

required by a chiropractor to diagnose such subluxation. A 

physician or chiropractor must document a diagnosis of 

spinal subluxation in his or her LMN as demonstrated by an 

x-ray before a CE can authorize services, and the spinal 

subluxation must be related to an accepted condition. 

7. Pulmonary Rehabilitation. The CE is required to 

authorize pulmonary rehabilitation services when prescribed 

by the treating physician. The treating physician must 

submit a LMN describing the need for pulmonary 

rehabilitation and its association to an accepted workrelated illness. The LMN must specify the type, amount, 

frequency, and duration of pulmonary rehabilitation. The 

LMN must also include measurable and expected outcomes and 

estimated timetables to achieve these outcomes. Pulmonary 

rehabilitation must be conducted in an outpatient hospital 

setting or doctor’s office. A CE may authorize pulmonary 

rehabilitation for a period of up to six months. 

Recertification is required for any period beyond six 

months. Recertification should be completed before the 

current authorization expires, to allow for care to 

continue uninterrupted. 

8. Hearing Aids. A claimant requesting hearing aid(s) 

must submit LMN from his or her treating physician. The LMN 

must contain an explanation for obtaining hearing 

assistance due to an accepted work-related hearing loss. 

Services associated with the assessment, provision or 

fitting of hearing aids must be rendered by a licensed 

otolaryngologist, otologist, audiologist, or hearing aid 

specialist. Hearing aids are limited to one per ear every 

three years. The CE must authorize needed repairs within 

the three-year period, if the manufacturer’s warranty has 

expired. 

 

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9. Organ Transplants (including Stem Cell). Organ 

transplants are a complicated and medically challenging 

treatment option. As a result, a special level of review is 

required. Once the FO alerts the CE to a request for organ 

transplant, the CE immediately obtains all relevant 

documentation from the treating physician relating to 

medical necessity of an organ transplant. In particular, 

the CE seeks a LMN describing the justification for the 

transplant, laboratory and diagnostic test results, CT or 

MRI scan results, and a transplant protocol. Once the CE 

has obtained this information, the CE forwards the 

information to the MBPU, via the DEEOIC Bill Pay Mailbox, 

requesting review for organ transplant authorization. The 

MBPU will then forward all pertinent information to the 

DEEOIC Medical Director, who prepares a memorandum 

approving or denying the transplant. The MBPU will then 

forward the signed memorandum to the jurisdictional office 

responsible for the claim. 

a. With notification of approval, the CE updates ECS 

Notes with a confirmation of organ transplant 

authorization. The CE then prepares a letter of 

authorization to the claimant with a copy to his or 

her physician. The letter is to provide notification 

on the organ transplant authorization including: 

(1) Covered medical condition(s). 

(2) Authorized billing code(s) relevant to the 

approval. 

(3) Statement advising that organ transplants 

must be performed at a Center for Medicare and 

Medicaid Services (CMS) approved facility. 

(4) Statement advising that fees are subject to 

the OWCP fee schedule. 

 

 (5) Statement advising that an organ donor is 

not considered an “employee” or “claimant” within 

the meaning of DEEOIC and is not entitled to 

compensation for wage-loss or permanent 

impairment, nor is a donor entitled to benefits 

for any post-operative complications resulting 

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from the transplant. Only those medical and 

related expenses of the donor, which are 

necessary to secure treatment for the employee, 

are allowable. 

b. In-Patient or Outpatient Setting. Depending upon 

the transplant center, the condition of the patient, 

and geographic limitations, transplant procedures may 

occur on an in-patient or outpatient basis. 

(1) Autologous transplants may be performed in 

either an in-patient or outpatient setting, 

depending upon the transplant center. This type 

of transplant requires stem cells that have been 

gathered and stored, coming directly from the 

patient. 

(2) Allogenic transplants may also be performed 

in either an in-patient or out-patient setting. 

Allogenic transplants require that donor-blood 

stem cells be drawn, stored, and then 

transplanted into the patient. 

c. Choice of Donors. 

(1) The first choice of a donor is generally a 

family member or relative. If the transplant 

facility approves a related donor, transportation 

expenses and the cost of required medical 

procedures for obtaining the organ(s) or blood 

stem cells are reimbursable. The transplant 

facility submits bills to the BPA, referencing 

the employee’s (recipient) Social Security Number 

(SSN), and including the medical documentation/ 

information pertaining to the donor. Donor 

travel is reimbursed following the same 

guidelines established for companion medical 

travel, and is paid directly to the employee. 

(2) If no suitable match is available through a 

relative, an unrelated donor search must be 

authorized. The transplant center coordinates 

with the National Donor Program for the testing 

of each potential donor. The transplant center 

submits bills to the BPA for all such tests and 

procedures. Unrelated donors are not paid for 

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their donation; the only coverage is for the 

medical expenses related to the organ donor 

procedure. These procedures are billed by the 

transplant facility, the same as with related 

donors, referencing the covered employee’s SSN on 

all bills. 

d. Long-Term Living Expenses. Transplants involve 

prolonged outpatient procedures requiring the patient 

to remain within a short distance of the transplant 

center. If the CE authorizes a transplant procedure 

and if the claimant requires extended residency near 

the facility, the CE must authorize lodging, per diem, 

companion, and other travel-related expenses on a 

long-term basis. 

10. Mental or Psychiatric Illness Treatment. A CE may 

accept a mental or psychiatric illness under a Part B or 

Part E claim as a consequential illness to another accepted 

illness. In these situations, the CE must obtain a 

narrative medical report from a licensed clinical 

psychologist, psychiatrist, or licensed clinical social 

worker which includes: 

a. Diagnosis (with correct ICD10 code) and the 

initial date of diagnosis. 

b. Medical rationale in support of how the mental or 

psychiatric illness is related to a condition accepted 

by the DEEOIC under Part B or Part E of EEOICPA. 

11. Experimental Treatment. The CE may consider 

authorizing experimental treatment if the accepted 

condition is life threatening, conventional therapy has 

been tried to no avail and a significant body of data 

supports the view that the experimental procedure is indeed 

beneficial. 

 

To request experimental treatment, the treating physician

must send the treatment protocol, medical rationale, and 

peer-reviewed documents supporting the treatment to the CE. 

The CE forwards the information to the MBPU via the DEEOIC 

Bill Pay Mailbox. The MBPU will forward all pertinent 

information to the DEEOIC Medical Director, who prepares a 

memorandum approving or denying the experimental treatment. 

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The MBPU will then forward the signed memorandum to the 

requesting district office. 

Upon receipt of the approval from the DEEOIC Medical 

Director, the CE sends an email to the FO, who prepares and 

sends a thread to the BPA, authorizing the experimental 

treatment approved by the DEEOIC Medical Director. The CE 

also documents the approval in the Notes section of ECS. The 

CE sends a copy of the approval letter to the provider 

designated by the claimant to provide the service. The 

approval letter must contain the following information: 

a. Covered medical condition(s). 

b. Authorized billing code(s) relevant to the 

approval. 

c. Statement advising that fees are subject to 

the OWCP fee schedule. 

12. Sun Protective Clothing. This section describes the 

procedures a CE follows when authorizing a claimant’s 

request for reimbursement of sun protective clothing. 

DEEOIC has established a maximum $400 limit for sun 

protective clothing per calendar year. Sun protective 

clothing used for general health or personal reasons is not 

covered. 

a. Sun protective clothing is clothing specifically 

designed for sun protection and is produced from a 

fabric rated for its level of ultraviolet protection. 

Sun protective clothing is clothing that offers at 

least 30 or more Ultraviolet-A (UVA) and Ultraviolet-B 

(UVB) sun protection for claimants with accepted 

conditions of melanoma, other skin cancer or other 

significant dermatologic condition. 

(1) For authorization, the CE obtains the 

following information: 

(i) A LMN from the treating physician 

describing a medical need for sun protective 

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(ii) The claimant must submit a receipt 

documenting that the clothing was purchased 

from a sun protective clothing company 

(i.e.; Solumbra or Coolibar). 

(2) Once appropriate documentation is received, 

the CE approves the reimbursement for the sun 

protective clothing using the OWCP procedure code 

Clothing Modifications - CLMOD. 

13. Vehicle Modifications and Purchases. This section 

provides clarification with regard to the evidence needed 

to approve vehicle modifications and purchases, and 

provides procedural guidance with regard to the process for 

review, development, and authorization of such requests. 

a. Criteria for Modifications. Upon receipt of a LMN 

describing a medical need for vehicle modification, 

and if the claimant’s medical needs can be met by 

modifying or adding accessories/equipment to the 

claimant’s present vehicle, the CE explores that 

option first, before considering replacement of the 

existing vehicle. When considering modifications to an 

existing vehicle, the CE takes into consideration the 

type of vehicle currently owned, its age, and 

condition. Modifications must be consistent with the 

claimant’s pre-injury standard of living and should 

approximate that standard insofar as practical. 

b. Proposals. If the CE determines that the 

claimant’s medical needs warrant vehicle modification, 

the CE advises the claimant in writing to submit a 

detailed written proposal containing the following 

information: 

(1) The year, make, model, and body style of the 

vehicle to be modified, as well as current 

mileage, description of general mechanical 

condition, and any modifications currently needed 

or anticipated. The same applies regardless of 

whether the vehicle to be modified is new or 

used. 

(2) Detailed written estimates from two licensed 

automobile dealers, or custom alteration 

facilities, itemizing the proposed vehicle 

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modifications necessary to comply with the 

treating physician’s LMN. Estimates must include 

a breakdown of all parts, labor, and the 

respective costs associated with each item. The 

estimates should also state the amount of time 

required to perform the modifications. 

c. Acceptance by the CE. The CE has the latitude to 

approve an estimate that the claimant favors, if the 

estimates are reasonably similar in scope and cost. 

(1) Approval or Denial. Upon review of the 

evidence, the CE approves or denies the request 

by sending a letter decision to the claimant 

advising of the approval, or reason(s) for denial 

of the request. 

(2) Additional Information. If the CE 

determines that additional information is 

necessary, the CE sends a letter to the claimant 

requesting the additional documentation that is 

necessary to continue with the review process. 

(3) Inadequate response. If the claimant does 

not respond to the development letter, or does 

not provide sufficient documentation to support 

the request, after considering all relevant 

evidence, the CE issues a letter decision 

informing the claimant of the authorization 

denial. 

d. Vehicle Purchase. If the claimant provides a LMN 

establishing that modifications to his or her 

currently owned vehicle are not feasible or practical, 

and that a substitute vehicle is required for the 

claimant to operate, the CE reviews the case with a 

supervisor and the National Office Fiscal Officer 

(NOFO), and may authorize the purchase of a suitable 

replacement vehicle. Under these circumstances, credit 

must be taken for the value of the claimant’s existing 

vehicle. Purchase options include the following: 

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quality to the claimant’s existing vehicle), 

equipped to accommodate the claimant’s disability 

and transportation needs. 

(2) Purchase of a used vehicle that is suitable 

for modification as described above. 

(3) Purchase of a new vehicle, modified, or 

suitable for modification, to meet the needs of 

the claimant, arising from an accepted condition. 

(4) Whether a new or used vehicle is purchased, 

it must be a vehicle of comparable value as the 

vehicle currently owned and operated by the 

claimant (i.e.; a vehicle in a price range that 

closely approximates the level of income and/or 

standard of living of the claimant). For example, 

if the claimant owns a mid-priced Chevrolet, 

Ford, Honda or Toyota, purchase of a Cadillac, 

Lincoln, or Lexus SUV, would not represent a 

vehicle of comparable value. Once the baseline 

cost of a comparable quality vehicle has been 

established, the claimant may (at his or her 

option) choose to upgrade the baseline model, by 

adding additional equipment, with the difference 

in cost being paid for by the claimant. 

(5) After determining the baseline cost of a 

comparable vehicle, the CE must take credit for 

(deduct) the wholesale value of the claimant’s 

existing car when determining the allowance to be 

paid for a replacement vehicle. The wholesale 

value of the existing vehicle can be determined 

through a number of internet websites that make 

this information available free-of-charge. The CE 

should advise the claimant of the source of their 

information, once the wholesale value of the 

claimant’s current vehicle has been determined. 

(6) Sales Tax. State sales tax should be 

included in the cost of obtaining a replacement 

vehicle. 

(7) Equipment that is medically necessary for 

the accepted condition should be factoryinstalled whenever possible. 

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(8) Maintenance Costs. The CE authorizes 

necessary maintenance on the specialized 

equipment in a modified vehicle, whether 

installed in a new or used vehicle. 

(i) Replacement cost of the specialized 

equipment, due to normal wear and tear, may 

be considered as well. Other parts of the 

vehicle will be maintained at the owner’s 

expense, even if the vehicle purchase was 

reimbursed by DEEOIC. 

(ii) Replacement of the vehicle, and all 

authorized equipment, can be considered if 

the claimant can establish that the age, 

mileage, and condition of the vehicle 

warrant such replacement. Any residual value 

remaining in the vehicle to be replaced 

would be applied as a credit toward the cost 

of a replacement vehicle. 

(9) Proof of Insurance. The claimant bears the 

cost of obtaining automobile insurance and 

maintaining current vehicular registration in 

conformance with the laws of the state within 

which the claimant resides. Claimants are 

required to carry comprehensive (fire, theft, 

vandalism) and collision insurance on any vehicle 

for which DEEOIC has authorized reimbursement, 

unless the fair market value of the vehicle and 

its equipment is less than $2,500. The claimant 

may select the deductible of the insurance policy 

but will be responsible for any such deductible 

should an accident occur. 

(10) Vehicle No Longer Needed. If the CE 

obtains information that a vehicle purchased by 

DEEOIC is no longer needed, the CE will send an 

email to the DEEOIC Bill Pay Box Mailbox alerting 

MBPU of the situation. DEEOIC is entitled to 

recover the fair market value of the purchased 

vehicle, less any percentage contribution the 

claimant made to the overall purchase price of 

the vehicle and its modifications. The MBPU will 

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undertake appropriate action to attempt recovery 

of any funds collectable through sale of a DEEOIC 

purchased vehicle no longer needed by a claimant. 

14. Housing Modifications. This section provides 

clarification with regard to the evidence needed to approve 

housing modifications, and provides procedural guidance 

with regard to the process for review, development, and 

authorization of housing modifications. The CE considers 

home modification only when deemed medically necessary due 

to an accepted condition. A CE’s responsibility is to grant 

authorization to modify an existing structure to 

accommodate the claimant’s medical needs. The treating 

physician must describe in a LMN the particular home 

modifications needed to accommodate the claimant’s workrelated illness. 

a. Modifications to Owned Property. Modifications 

to a house must be consistent with the claimant’s preinjury standard of living and should approximate that 

standard insofar as practical, with respect to the 

quality of construction materials and workmanship. 

(1) Modifications may include certain additions 

where warranted. For example, if a ground-floor 

recreation room is converted to a bedroom, to 

accommodate a wheelchair-bound individual, and if 

no ground-floor bathroom facilities exist, then 

the addition of a bathroom on the ground floor 

could be approved. Similarly, if there is no 

suitable space for conversion of a bedroom on the 

ground floor, then the addition of a bedroom on 

the ground floor could be approved, if no other 

reasonable alternative exists. 

(2) Modifications may include certain 

appliances, such as air conditioning or air 

filtration equipment, if deemed to be medically 

necessary by the treating physician, and 

necessary for the relief of accepted medical 

conditions. For example, if the claimant suffers 

from respiratory or cardiac conditions that have 

been accepted, his or her physician may order 

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that the claimant be kept in an air conditioned 

environment, in which case the expense for these 

modifications would be allowed. 

(3) When considering modification requests, the 

CE should consider whether a portion of a home 

can be modified, as compared to a whole-house 

modification. An example of this would be one or 

two room air conditioning units, versus 

installing a whole-house air conditioning system. 

(4) Maintenance expenses. The CE approves 

maintenance expenses for equipment furnished 

to the claimant, as well as replacement costs, 

after the normal life expectancy of the 

appliance. 

b. Modifications to Non-Owned Property. Any 

modifications to property not owned by the claimant, 

and his or her family, are subject to approval by the 

landlord or owner. This is in addition to the 

preceding guidelines established for owned property.

When presented with a request for modifications to 

non-owned property, the CE considers the following 

points: 

(1) Rental property may be subject to federal 

Americans with Disabilities Act (ADA), state, or 

local statutes that mandate barrier-free 

accessibility for persons with disabilities. The 

claimant should discuss any change in housing 

needs with his or her landlord, who may be able 

to offer modifications or alternative 

accommodations better suited to the needs of the 

individual. 

(2) If the landlord is unable or unwilling to 

pay for modifications, or offer other suitable 

accommodations, approval must still be obtained 

from the landlord prior to making any changes or 

alternations to the non-owned property. Any such 

changes must be made at the claimant’s expense, 

and are subject to review and approval by DEEOIC, 

prior to any reimbursement. 

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(3) If the landlord/owner will not permit 

modifications, or if the costs are excessive, and 

if suitable housing arrangements are available 

elsewhere, within the same geographic area, it 

may be more cost-effective to consider paying 

relocation expenses rather than paying for 

modifications at the current location. If 

changing locations is the most cost-effective 

alternative, the CE may authorize a subsidy for 

any increase in rent, if warranted, in addition 

to the relocation expense. For example, if the 

claimant lives in an apartment with stairs, and 

is no longer able to climb stairs due to his or 

her accepted condition(s), DEEOIC would reimburse 

the claimant for the most nearly comparable 

apartment available that offers an elevator and 

any other accommodations required to fulfill the 

claimant’s medical needs arising from the 

claimant’s accepted condition(s). 

(4) The Government is entitled to reimbursement 

only for the value of special equipment that can 

be removed and sold separately, once the claimant 

no longer needs that equipment. Improvements or 

modifications, and any increase in property value 

resulting from such changes, accrue to the 

benefit of the owner. 

c. Proposals. If the CE determines that the 

claimant is eligible for housing modifications, the CE 

asks the claimant to submit a detailed written 

proposal for review and consideration. The CE advises 

the claimant that the proposed housing modifications 

should be of a quality and grade consistent with the 

existing architecture and construction materials, not 

superior to them. Further, the claimant should be 

cautioned that structural modifications must not 

compromise the integrity of the existing structure. 

Modifications will be no more expensive than necessary 

to accomplish the required purpose. For example, when 

remodeling a bathroom, it may be feasible to reinstall an existing sink at wheelchair height, for 

less than the cost of discarding the sink and buying a 

new one. 

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Conversely, modifications must be in keeping with the 

standard of the décor of the current or preillness accommodations. For example, if the claimant’s 

dwelling requires that a sink or commode be changed 

for handicap accessibility, and if it is necessary to 

tear out and replace tile, then the tile in the entire 

bathroom or kitchen may have to be replaced with 

similar quality tile in order to maintain the 

architectural décor of the room. 

Proposals must include the following information: 

(1) A medical report detailing the physical 

limitations for which the requested modifications 

are necessary. This report should be prepared by 

a physician who is a recognized authority in the 

appropriate medical specialty. 

(2) An itemization of all modifications 

proposed. Where substantial modifications are 

required, the detailed changes should be 

recommended by a medical or rehabilitation 

professional familiar with the needs of the 

disabled. 

(3) If the claimant lives in a rented or nonowned premise, a written statement from the 

landlord/owner must be obtained, approving and 

authorizing the specific plans and proposed 

modifications. 

(4) The CE reviews the itemized proposal and 

determines if the specified modifications are 

warranted. If the CE identifies technical issues 

regarding implementation, the CE develops the 

issue further to identify alternate solutions. 

d. Fees and Bids. 

(1) Reasonable fees may be paid for the medical 

or rehabilitation professional’s visit to the 

site, and for the preparation of the detailed 

report. The same applies to any architectural 

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drawings that are required for significant 

structural changes. 

(2) No fee will be paid for attorneys or similar 

representatives engaged by the claimant to assist 

with the proposal. Any fee charged by an 

Authorized Representative remains the claimant’s 

obligation. 

(3) The claimant must provide two or more bids 

for the proposed changes from licensed and/or 

certified contractors. The bids submitted must be 

for exactly the same modifications so that 

comparison of the competitive bids can be made. 

(i) If construction work is required, the 

bids obtained must be for binding estimates 

of the cost. No fees will be paid for the 

bids or estimates. 

(ii) If special accessories or devices are 

required, the CE stipulates that the price 

quoted by the vendor includes any necessary 

installation. 

(4) The CE reviews the bids to determine that 

the same workmanship and materials are specified 

in the competitive bids, and normally selects the 

lowest cost bid, unless there is a sound reason 

for a higher-cost alternative, such as increased 

durability. If the CE selects a bid other than 

the lowest-cost bid, a memorandum to the file is 

required, explaining any variance or the 

justification for accepting a higher bid. 

(5) Additional Information. If the CE 

determines that additional information is 

necessary, the CE sends a letter to the claimant 

requesting additional documentation that is 

necessary to continue with the review process. 

e. Approval and Payment Options. Upon approval of 

the request, the CE writes a detailed letter decision 

to the claimant advising of the approval (Exhibit 6 

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provides a sample of the home modification approval 

letter.) The approval letter is to include guidance to 

the claimant of the payment options available and 

requests that the claimant respond in writing, 

indicating his/her preferred payment option. For 

payment of home modification, the following is 

necessary: 

(1) The claimant submits medical evidence and 

two proposals for home modifications. Upon review 

the CE approves the lower cost bid proposal and 

sends a letter to claimant stating DEEOIC agrees 

to the approved scope and cost of repairs, and, 

at the claimant’s request, will make direct 

payment to the enrolled contractor, once the 

agreed upon work has been completed. The letter 

states that upon completion of the agreed-upon 

work, the claimant must submit a written 

attestation to DEEOIC stating that the agreed 

upon work has been completed by the contractor, 

to the claimant’s satisfaction, and requesting 

that payment be made to the contractor. The CE 

sends a courtesy copy of this letter to the 

contractor. 

(2) Upon receipt of the claimant’s attestation 

and request to pay the contractor, the CE 

acknowledges the claimant letter and advises that 

the enrolled contractor should submit Form OWCP1500, along with a final invoice, in order to 

receive payment of the agreed upon price. The 

OWCP Code for HOME MODIFICATION - HSMDF is used, 

when preparing the Form OWCP-1500. 

(3) In certain situations, the CE may authorize 

payment of a pre-construction deposit if required 

by the contractor whose bid has been accepted by 

the CE. In these situations, the contractor is to 

specify the total cost for specified home 

modification, along with the amount of any 

deposit (up to one-third of the total cost) 

required to initiate work. With CE approval, the 

contractor may then submit Form OWCP-1500, to 

receive partial payment for the deposit amount of 

the estimated cost. The OWCP code for HOME 

MODIFICATION - HSMDF is used when preparing the 

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Form OWCP-1500. Upon completion of the work, the 

claimant must submit a written attestation to 

DEEOIC stating that the agreed upon work has been 

completed by the contractor, to the claimant’s 

satisfaction, and requesting that final payment 

be made to the contractor. The contractor submits 

a separate Form OWCP-1500, requesting payment of 

the balance of the agreed upon amount. 

(4) For guidance regarding problems encountered 

during the course of home modifications, or for 

other billing questions, (e.g.; billing 

difficulties, disputes or other irregularities), 

the CE should contact the National Office Policy 

Branch for assistance. 

15. Health Facility Membership and Spa Membership. This 

section describes procedures when a claimant requests 

authorization for reimbursement of fees to join a 

commercial health club or spa. 

a. Authorization. Membership in a health club or 

exercise facility, or treatment at a spa, may be 

authorized when recommended by the treating physician 

as likely to treat the effects, cure or give relief 

from a covered illness. All requests for reimbursement 

of health facility and spa fees require prior 

authorization from the CE. In all cases where such 

membership is requested, the CE determines 

whether the membership is likely to be effective and 

cost-efficient. 

b. Payment. Whenever a request for payment of 

health club/spa membership is received, the CE obtains 

the following information: 

(1) Information from Physician. The CE obtains 

the following information from the treating 

physician: 

(i) A description of the specific therapy 

and or exercise routine needed to address 

the effects of the covered illness, 

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including the frequency with which the 

exercises should be performed. 

(ii) The anticipated duration of the 

recommended regimen (i.e.; weeks, months). 

(iii)An opinion as to the actual/anticipated 

effectiveness of the regimen, treatment, 

goals attained/sought, and frequency of 

examinations to assess the continuing need 

for the regimen. 

(iv) A description/list of the specific 

equipment and or facilities needed to safely 

perform the regimen. 

(v) The nature and extent of supervision, if 

any, required for the safety of the claimant 

while performing the exercises. 

(vi) An opinion stating whether exercise can 

be performed at home, as part of a home 

exercise program, or a recommendation as to 

what kind of public or commercial facility 

could provide the prescribed exercise 

routine. 

(2) Information from Claimant. In addition, the 

CE obtains the following information from the 

claimant: 

(i) The full name, address, and distance 

from the claimant’s home or work location, 

of any public facilities (no membership 

required) and those commercial facilities 

(membership required) able to accommodate 

the prescribed regimen. 

(ii) If applicable, the specific reason(s) 

membership in a commercial health club/spa 

is required when public facilities are 

available, and or where the doctor indicates 

SUPERSEDED

the regimen can be performed at home. 
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

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(iii) A signed statement from the health 

club/spa manager stating that the club/spa 

can fully provide the exercise regimen 

prescribed by the treating physician, and a 

breakdown of the fees and charges for 

various membership options and terms. The 

statement should describe all facilities, 

services, and special charges not included 

in the membership fee. 

c. Approval. 

(1) The CE must write a letter to the claimant 

advising of the approval. The letter must 

include the following:

(i) The date the DO received the request. 

(ii) The period of time which the approval 

will cover. 

(iii)The amount approved (i.e.; monthly or 

 annual fee). 

(iv) The type of membership approved. 

(v) Two copies of a blank OWCP-957. 

d. Additional Information. If the CE determines 

that additional information is necessary, the CE sends 

a letter to the claimant (with a copy to the treating 

physician) requesting additional documentation that is 

necessary to continue with the review process. In the 

letter, the CE provides 30 days for receipt of the 

requested information. 

e. Period of Service. The CE may approve health 

facility membership for up to twelve months. 

Recertification is required for any period beyond 

twelve months. 

16. Medical Alert Systems. This section describes 

procedures the CE follows when a claimant requests 

authorization for medical alert system. 

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a. Definition. A medical alert system is an 

electronic device connected to a telephone line. In an 

emergency, the system can be activated by either 

pushing a small button on a pendant or pressing the 

help button on the console unit. When the device is 

activated, a person from the 24-hour central 

monitoring station answers the call, speaks to the 

claimant via the console unit, assesses the need for 

help, and takes appropriate action. A medical 

communication system qualifies as a medical alert 

system if it includes the following requirements: 

(1) An in-home medical communications 

transceiver; 

(2) A remote, portable activator (Personal 

Pendant); 

(3) A central monitoring station staffed by 

trained attendants 24 hours a day, seven days a 

week (optional). 

b. Authorization. All requests for medical alert 

systems require prior authorization from the CE. A 

request for a medical alert system must be documented 

with a letter of medical necessity from the treating 

physician, linked to the accepted condition, which 

includes a statement that the claimant has an acute or 

chronic condition which can require urgent or 

emergency care. 

(1) Period of Service. The CE may authorize the 

medical alert system for up to twelve months at a 

time. The need for such equipment should be 

recertified by the prescribing physician prior to 

the expiration of the authorization period. 

(2) Billing. Systems that require a one-time 

connection fee and monthly monitoring fee may be 

approved, based on the claimant’s needs and the 

medical justification. The equipment provided is 

leased and must be returned when no longer needed 

to avoid further charges. DEEOIC is not 

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responsible for any additional charges incurred 

for failure to return equipment or failure to 

timely return the equipment in a timely manner. 

c. Approval. 

(1) The CE writes a letter to the claimant 

advising of the approval. The letter includes the 

following: 

(i) The date the DO received the request; 

(ii) The period of time which the approval 

will cover; 

(iii) The amount approved. 

d. Additional Information. If the CE determines 

that additional information is necessary, the CE sends 

a letter to the claimant (with a copy to the treating 

physician) requesting specific documentation that is 

necessary to continue with the approval process. In 

the letter, the CE provides 30 days for receipt of the 

requested information. 

17. Medical Expense Reimbursement for Extended Travel. 

This section describes procedures to be followed for 

authorizing medical travel requests over 200 miles roundtrip, and the process for approving claims for 

reimbursement, regardless of whether the claimant obtained 

prior approval for the trip. 

a. Authorization. DEEOIC requires pre-authorization 

for reimbursement of transportation, lodging, meals, 

and incidental expenses incurred when a claimant 

travels in excess of 200 miles round trip for medical 

care of an approved condition. DEEOIC’s BPA processes 

reimbursement claims for claimant travel without 

pre-authorization when travel is 200 miles or less 

round trip. (Exhibit 7 provides a sample Travel 

Authorization Letter.) 

b. Processing. DEEOIC’s BPA processes reimbursement 

claims in accordance with GSA travel guidelines. Per 

diem rates for overnight stay and mileage 

SUPERSEDED
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 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

reimbursement rates are published on the Government 

Services Administration (GSA) website, and air fare 

reimbursement is based on actual ticket cost up to the 

amount of a refundable coach ticket (Y-Class airfare). 

c. Prior Approval. Upon acceptance of a medical 

condition, the claimant receives a medical benefits 

package from the DEEOIC that includes instructions on 

how to submit a written request for prior approval of 

medical travel when such extended travel (over 200 

miles round trip) is required. Despite these 

instructions, it is not uncommon for claimants to 

submit their request for reimbursement after a trip 

has been completed, and without having obtained prior 

approval. 

 (1) Travel Exceeding 200 Miles. Medical expense 

reimbursement for travel exceeding 200 miles 

round trip must be authorized by the CE. Claims 

that are submitted to DEEOIC’s BPA, for 

reimbursement of travel expenses arising from 

medical travel in excess of 200 miles roundtrip, 

will not be processed for payment unless 

authorization has been provided by the district 

office. 

d. Requests. Upon receipt of a travel authorization 

request from the claimant, the CE takes immediate 

action to ensure that the request meets one basic 

requirement: that the medical treatment or service is 

for the claimant’s approved medical condition(s). The 

medical provider’s enrollment in the DEEOIC program is 

not a prerequisite to approving medical travel if the 

claimant chooses to receive medical services from a 

non-enrolled provider. 

(1) Companion. If the travel request involves 

authorization for a companion to accompany the 

claimant, the claimant must provide medical 

justification from a physician. The justification 

must be in written form, relating the treatment 

to the accepted condition and rationalizing the 

need for the companion. If the doctor confirms 

that a companion is medically necessary, and 

provides satisfactory rationale, then the CE may 

SUPERSEDED
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 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

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approve companion travel. In the alternative, the 

CE can authorize the claimant to stay overnight 

in a hospital or medical facility, and can 

approve payment for a nurse or home health aide 

if a companion is not available. The CE must use 

discretion when authorizing such requests and may 

approve one of the above alternatives when there 

is a definite medical need, accompanied by 

written justification from the physician. 

(2) Mode of Travel. The CE may allow the 

claimant to specify his or her desired mode of 

travel. It is the CE’s role to authorize the 

desired mode of travel for the time period(s) 

requested. When a request is received from the 

claimant that does not identify the mode of 

transportation, the CE contacts the claimant by 

telephone and assists in determining the desired 

mode of travel. (Resource Center staff may assist 

in this process.) 

e. Approval. Once the basic requirements for travel 

over 200 miles are met, as outlined above, the CE 

prepares and sends the claimant a travel authorization 

letter following the guidelines below. The CE may 

approve an individual trip, or any number of trips 

within a specified date range, all in one letter to 

the claimant. Once an initial authorization letter has 

been sent, future visits to the same doctor or 

facility may be approved by telephone, and confirmed 

by a follow-up letter. 

f. Authorization Letter. The authorization letter 

delineates the specifics of the trip being authorized, 

based upon the mode of travel the claimant has 

selected. In the travel authorization letter, the CE 

advises the claimant that travel costs are 

reimbursable only to the extent that the travel is 

related to obtaining medical treatment. In the letter, 

the CE also invites the claimant to contact the 

nearest Resource Center for assistance prior to or 

upon completing any trip to complete Form OWCP-957, 

SUPERSEDED

Request for Reimbursement. 
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

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Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

g. Adjudication. When adjudicating claims submitted 

after the trip has been completed, but for which prior 

approval was not obtained, the CE follows the same 

steps as for pre-authorized trips, to the point of 

sending an authorization package. At that point the CE 

sends only the authorization (or denial) letter to the 

claimant, not an entire authorization package. 

h. Notifying the BPA. In conjunction with sending 

the claimant an approval or denial of a travel 

request, the CE conveys his/her decision to DEEOIC’s 

BPA via the office’s FO, who is the point of contact 

with DEEOIC’s BPA for such issues. The CE prepares an 

e-mail to the FO, who in turn generates an electronic 

thread to the BPA. In the e-mail the CE provides the 

information specified below. The CE must also enter 

the following information into ECS: 

(1) Approved dates for a single trip or in the 

alternative, a date range and number of trips 

authorized within that time frame. 

(2) Approved mode of transportation. 

(3) Starting point and destination, (e.g.; 

claimant address and provider address, city & 

state at a minimum). 

(4) Authorization for rental car reimbursement, 

if appropriate. 

(5) Companion travel if approved. 

i. Approval Package. The approval package must 

include the following: 

(1) Two copies of the detailed authorization 

letter. 

(2) Two copies of a blank OWCP-957. 

(3) A prepaid express mail envelope, addressed 

to DEEOIC’s BPA, for the claimant’s use. 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

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Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

18. Ancillary Services or Expense Authorization 

Recommended Decision. When a CE decides to deny 

authorization for a claimed ancillary service or expense 

discussed in this chapter, the CE sends a letter decision 

to the claimant. The letter decision is to include a 

narrative explanation as to why the evidence is 

insufficient to warrant authorization. The CE is to send a 

copy of the letter decision to the provider, if 

applicable. 

a. The letter decision is to include the following 

language: 

 

If you disagree with this decision and 

wish to request a formal decision, please 

 immediately advise this office, in writing, that 

 you wish to have a Recommended Decision issued in 

 this case, providing you with your rights of 

 action. 

Upon issuance of the denial letter, the CE creates 

correspondence in ECS documenting the issuance of the 

decision letter denying the ancillary medical service. 

b. Recommended Decision. Should the claimant 

request a Recommended Decision regarding denial of an 

ancillary medical service or related expense, the CE 

completes the Recommended Decision process in 

accordance with existing DEEOIC procedure. In 

particular, the CE ensures that the narrative content 

of the Explanation of Finding includes a well-written 

discussion of the justification for the denial of 

authorization. The FAB is responsible for 

independently evaluating the recommendation of the CE, 

along with the file evidence, and deciding whether to 

finalize the recommended decision. 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

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Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 1 

Page 1 of 2 

 

Sample Ancillary Medical Services Development Letter

Date:

Claimant: (or Auth Rep/Provider) Case ID:

Street Address Accepted Condition(s):

City, State, Zip

Dear [Enter Claimant or Auth Rep]:

I am writing to you concerning your benefits under the 

Energy Employees Occupational Illness Compensation Program 

Act (EEOICPA). We have received a request for 

authorization for the [Enter type of ancillary medical 

service requested]. In order to properly evaluate and 

respond to this request, we need additional information 

from you. 

Please provide our office with the following information:

(Request only that information that is necessary to process 

the claim. Feel free to modify the following, if 

necessary.)

o Prescription from your treating physician (should 

include diagnosis code(s) for the condition for which 

the item(s) is being prescribed).

o Letter of Medical Necessity or other medical 

documentation (describe the general information a LMN 

is to provide. 

o Claimant information such as name, case file number, 

date of birth, and telephone number.

o Provider or vendor information such as name, provider 

address, ACS provider number, Tax ID number, national 

provider identification number, telephone number, and 

fax number.

o Treating physician contact information such as name, 

address, telephone number, and fax number.

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 1 

Page 2 of 2 

o DME information such as diagnosis code, HCPCS/CPT, 

modifier, quantity, purchase price, rental price, 

total cost, begin date, end date, and duration of use. 

You have 30 calendar days to provide the additional 

information. Your lack of response or submission of 

insufficient evidence will result in a denial of the 

request. 

In the interest of expediting the approval of your request 

for [Enter type of Ancillary Medical Service], please fax 

the requested information to the DEEOIC Bill Processing 

Agent at (800) 882-6147, within 30 days, or contact me if 

you have questions regarding this request. 

Thank you for your assistance. 

Sincerely,

[Enter POC CE Name and Signature]

[Enter POC CE Telephone and Fax Numbers]

cc: [Enter as appropriate]

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 1 

Page 2 of 2 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 2 

Page 1 of 2 

SAMPLE ANCILLARY MEDICAL SERVICES AUTHORIZATION LETTER

Date:

Claimant Name (or Auth Rep)

Street Address

City, State, Zip

 Re: Case ID [Enter Case ID Number]

Dear [Enter Claimant or Auth Rep Name]:

This letter is in reference to your claim for benefits 

under the Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA).

The Division of Energy Employees Occupational Illness 

Compensation (DEEOIC) recently received a request for 

authorization for [Enter the ancillary medical service] for 

the following covered medical condition(s):

List the covered condition(s):

After a thorough review of your case file, including 

communication with your treating physician (if applicable), 

the following authorization is granted:

[Enter type of ancillary medical service and 

billing code(s)] for the period of [Enter to 

and from date] from [Enter vendor name]. 

Note that the DEEOIC requires that the approved vendor 

noted above be enrolled as a provider in our medical bill 

payment system to be reimbursed. Vendors may call toll 

free 1-866-272-2682 for program enrollment information or 

for answers to payment questions. 

All fees for the ancillary medical service is subject to 

the OWCP Fee Schedule. 

 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 2 

Page 2 of 2 

If you have any questions or concerns regarding this 

authorization, please call your claims examiner at (XXX) 

XXX-XXXX. 

Sincerely, 

[Enter CE name]

DEEOIC Claims Examiner

cc: [Enter supplier name] 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 3 

Page 1 of 3 

Sample Development Letter (DME, Oxygen Therapy Equipment 

and/or Oxygen Medical Supplies) 

Date:

Claimant: (or Auth Rep/Provider) Case ID:

Street Address Accepted Condition(s):

City, State, Zip

Dear [Enter Claimant or Auth Rep]:

I am writing to you concerning your benefits under the 

Energy Employees Occupational Illness Compensation Program 

Act (EEOICPA). We have received a request for 

authorization for the [rental/purchase] of a [Enter type of 

DME, Oxygen Therapy Equipment and/or Oxygen Medical 

Supplies requested]. In order to properly evaluate and 

respond to this request, we need additional information 

from you. 

Please provide our office with the following information:

(Request only that information that is necessary to process 

the claim. Feel free to modify the following, if 

necessary.)

o Prescription from your treating physician (should 

include diagnosis code(s) for the condition for which 

the item(s) is being prescribed).

o Letter of Medical Necessity or other medical 

documentation (describe the general information a LMN 

is to provide. 

o Claimant information such as name, case file number, 

date of birth, and telephone number. 

o Provider or vendor information such as name, provider 

address, ACS provider number, Tax ID number, national 

provider identification number, telephone number, and 

fax number.

o Treating physician contact information such as name, 

address, telephone number, and fax number.

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 3 

Page 2 of 3 

o DME information such as diagnosis code, HCPCS/CPT, 

modifier, quantity, purchase price, rental price, 

total cost, begin date, end date, and duration of use. 

 

o Diagnostic testing that supports the physician’s 

reasons for prescribing oxygen therapy DME or oxygen 

medical supplies, and identifies clear, objective 

pulmonary deficits including results from an arterial 

blood gas (ABG) and/or resting/exercise spirometry 

test, and/or nocturnal oximetry studies. The results 

are to identify the conditions under which the 

test(s)/studies were performed; (i.e.; during 

exercise, at rest, or during sleep). The test(s) are 

to be performed by a qualified medical professional, 

and originate from a qualified source such as a 

laboratory, diagnostic testing facility, hospital, 

physician’s office or clinic. 

Note that add-ons and/or upgrades to Oxygen Therapy 

Equipment and/or Oxygen Medical Supplies will be considered 

for approval if evidence substantiates a medical need for 

the enhancement. However, add-ons and/or upgrades to 

Oxygen Therapy Equipment and/or Oxygen Medical Supplies are 

not covered when they are intended primarily for the 

claimant’s convenience and do not significantly enhance 

functionality. 

You have 30 calendar days to provide the additional 

information. Your lack of response or submission of 

insufficient evidence will result in a denial of the 

request. 

In the interest of expediting the approval of your request 

for [Enter type of DME, Oxygen Therapy Equipment and/or 

Oxygen Medical Supplies], please fax the requested 

information to the DEEOIC Bill Processing Agent at (800) 

882-6147, within 30 days, or contact me if you have 

questions regarding this request. 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 3 

Page 3 of 3 

Thank you for your assistance. 

Sincerely,

[Enter POC CE Name and Signature]

[Enter POC CE Telephone and Fax Numbers]

cc: [Enter as appropriate]

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 4 

Page 1 of 2 

Sample Authorization Letter (DME, Oxygen Therapy Equipment 

and/or Medical Supplies) 

Date:

Claimant Name (or Auth Rep)

Street Address

City, State, Zip

 Re: Case ID [Enter Case ID Number]

Dear [Enter Claimant or Auth Rep Name]:

This letter is in reference to your claim for benefits 

under the Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA).

The Division of Energy Employees Occupational Illness 

Compensation (DEEOIC) recently received a request for 

authorization for the [Enter purchase or rental] of a 

[Enter the Durable Medical and/or Oxygen Therapy Equipment 

and/or Medical Supplies] for the following covered medical 

condition(s):

List the condition(s)

After a thorough review of your case file, including 

communication with your treating physician (if applicable), 

the following authorization is granted:

Rental of [Enter type of Durable Medical and/or 

Oxygen Therapy Equipment and/or Medical 

Supplies and billing code(s) for the period] of 

[Enter to and from date] from [Enter vendor 

name]. 

If the rental is converted to a purchase, the 

purchase reimbursement price must be less than 

the paid rental price.

Purchase of [Enter type Durable Medical and/or 

SUPERSEDED

Oxygen Therapy Equipment and/or Medical 
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 4 

Page 2 of 2 

Supplies and billing code(s)] from [Enter 

vendor name].

Note that the DEEOIC requires that the approved vendor 

noted above be enrolled as a provider in our medical bill 

payment system to be reimbursed. Vendors may call toll 

free 1-866-272-2682 for program enrollment information or 

for answers to payment questions. 

Reimbursement claims must be submitted with the appropriate 

modifier to receive payment for Durable Medical and/or 

Oxygen Therapy Equipment and/or Medical Supplies. 

All fees for the rental/purchase of Durable Medical and/or 

Oxygen Therapy Equipment and/or Medical Supplies are 

subject to the OWCP Fee Schedule. 

Add-ons and/or upgrades to the Durable Medical and/or 

Oxygen Therapy Equipment and/or Medical Supplies are 

considered for approval if evidence substantiates a medical 

need for the enhancement. However, add-ons and/or upgrades 

to Durable Medical and/or Oxygen Therapy Equipment and/or 

Medical Supplies are not covered when they are intended 

primarily for the claimant’s convenience and do not 

significantly enhance the equipment/supplies 

functionality. 

If you have any questions or concerns regarding this 

authorization, please call your claims examiner at (XXX) 

XXX-XXXX. 

Sincerely, 

[Enter CE name]

DEEOIC Claims Examiner

cc: 

SUPERSEDED

[Enter supplier name]
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 4 

Page 2 of 2 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 5 

OXYGEN DELIVERY SYSTEMS

GASEOUS OXYGEN SYSTEM – This consists of an oxygen tank 

with a regulator/flowmeter. This is a compressed gas 

system. A regulator/flowmeter is attached to the tank via 

an oxygen wrench. The flow rate is controlled by adjusting 

the knob on the regulator/flowmeter. Oxygen tanks, no 

matter how large or small, are all portable. 

OXYGEN CONCENTRATOR – An oxygen concentrator is a device 

which takes ambient or room air and divides the air into 

oxygen and nitrogen. The nitrogen is discarded and the 

oxygen is stored, concentrated, and delivered to the 

patient at 90-95% purity. A stationary concentrator is 

most typically utilized inside the patient’s home. A 

stationary system runs on electricity. A stationary system 

has a regulator/flowmeter built into the device. A 

stationary system typically has a single delivery port and, 

depending upon the model, can deliver up to 8 liters per 

minute (LPM) of oxygen to the patient. A portable oxygen 

concentrator is most typically utilized outside the 

patient’s home. A portable system runs on a battery that 

must be recharged periodically. The battery recharger runs 

on electricity. Typical battery life for a portable oxygen 

concentrator is approximately 4 hours. 

 

LIQUID OXYGEN SYSTEM – Liquid oxygen systems consist of a 

stationary unit or reservoir which stores a large volume of 

liquid oxygen and a portable unit which can be refilled 

from the stationary unit. Neither the stationary or 

portable units require electricity. 

 

MECHANICAL VENTILATOR – Mechanical ventilation may be 

defined as a life-support system designed to replace or 

support normal ventilator lung function. Mechanical 

ventilation serves only to provide assistance for breathing 

and does not cure a disease process. Mechanical 

ventilators require electricity and a skilled professional 

(M.D., D.O., PA, NP, RN, or RRT) to monitor the patient and 

SUPERSEDED

the ventilator settings.
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 6 

Page 1 of 3 

Sample Home Modification Letter 

[Date] 

[Claimant Name or AR Name]

[Street Address] 

[City, State, Zip]

Employee: 

Case ID: 

[Insert Employee 

Name] 

XXXXX 

Dear [Insert Employee or AR Name]: 

This letter is in reference to your claim for medical 

benefits under the Energy Employees Occupational Illness 

Compensation Program Act (EEOICPA). 

The Division of Energy Employees Occupational Illness 

Compensation (DEEOIC) recently received an authorization 

request for home modifications related to your accepted 

medical condition(s). 

Along with your request we also received a copy of your 

letter of medical necessity, prescribing [Insert brief 

description of modifications prescribed by letter of 

medical necessity]. Additionally, we received the two, 

detailed contractor estimates, describing the scope and 

cost of the proposed modifications. 

After a careful review of your request, we have determined 

that the evidence submitted is sufficient to authorize your 

request for home modification. The request is approved

subject to the following conditions: 

• The DEEOIC is approving modifications based upon the 

proposal submitted by: [Insert Name and Address of 

Contractor and Date of Proposal, for the approved 

bid.] 

• The total approved cost for all work, including 

SUPERSEDED

materials, labor, profit and overhead is the amount of
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 6 

Page 2 of 3 

[Insert Approved Dollar Amount] as stated in the 

proposal. 

• Upon completion of the approved modifications, you 

must submit a signed letter to DEEOIC advising that 

all of the approved work has been completed, and that 

the work has been completed in a satisfactory manner. 

Along with your letter you must submit a completed 

OWCP Form 915 (Claim For Medical Reimbursement), a 

final invoice for the charges billed, and proof of 

payment to the contractor. 

• If you want DEEOIC to pay the contractor directly, it 

will be necessary for the contractor to enroll in our 

medical bill processing system in order to receive 

payment. Contractors seeking additional enrollment 

information can call our toll-free number (866-272-

2682) for answers to billing questions. Once the 

approved work has been completed, it will be necessary 

for you to write us advising that all work has been 

completed in a satisfactory manner, and that you are 

requesting DEEOIC to make payment directly to the 

contractor, for the pre-approved amount. 

• Once DEEOIC has approved a written proposal for 

medically necessary modifications, you have the option 

of contracting for additional modifications, or for 

materials and appliances that represent an upgrade 

from the medically necessary standard prescribed. You 

may do so with the understanding that DEEOIC will only 

reimburse you for the cost of medically necessary 

modifications approved in writing. Reimbursement for 

the approved amount will be made to you upon 

completion of all work, and upon receipt of the 

following: 

o A letter from you stating that all work, as 

detailed in the approved modification proposal, 

has been completed to your satisfaction. 

o A final invoice from the contractor itemizing the 

cost of the completed work. 

o Proof of payment to the contractor for an amount 

no less than the amount approved for 

SUPERSEDED

reimbursement by DEEOIC.
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 6 

Page 3 of 3 

• The DEEOIC neither endorses nor sponsors any entity 

providing services to beneficiaries of our program. 

If you have any questions or concerns regarding this 

authorization please call me at [Insert Telephone Number]. 

Sincerely, 

[Enter CE Name] 

Claims Examiner 

Copy To: Authorized Representative 

Copy To: Contractor 

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 7 

Page 1 of 4 

Sample Travel Authorization Letter 

Date: 

Claimant Name (or Auth Rep): 

Street Address 

City, State, Zip 

Dear Claimant Name (or Auth Rep): 

This letter is in reference to your request for medical 

travel authorization under the Energy Employees 

Occupational Illness Compensation Program Act. You (or you 

and your companion) are authorized to travel for medical 

treatment with (Insert name of doctor or medical facility) 

in (City / State). Outlined below are the itemized travel 

allowances approved for your trip: 

• Dates of Trip: (Insert authorized travel dates)

[Or in the alternative] 

• Multiple Trips Authorized (Insert Authorized 

travel date range)

• Trip Origin & Destination: (Insert starting 

City/State and ending points) 

• Authorized mode of travel (Insert approved 

mode: auto, air, etc.) 

• Meals & Incidental Expenses (M&IE) See below. 

• Lodging (single or double occupancy) See 

below.

• Airfare allowance See below. 

• Mileage allowance for personal vehicle (Insert 

appropriate mileage rate or N/A)

• Companion approved to travel: (Insert name of 

companion or N/A] 

• Rental car reimbursement Indicate “YES” or N/A]

Companion Travel: If you have been authorized a companion 

to accompany you on this trip, you will be reimbursed at 

twice the daily M&IE rate and lodging will be based upon 

double-occupancy, unless otherwise approved. If travel is 

by commercial airline, then the companion airfare will be 

reimbursed as well. The expenses for your companion will

SUPERSEDED
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 7 

Page 2 of 4 

be paid to you, not to the companion, or any other party.

Travel Changes: We understand your travel may not happen 

as originally planned. If you encounter a change in your 

travel plans (such as an extended stay) that may result in 

additional expenses, please contact me or the DEEOIC 

Resource Center identified below at your earliest 

convenience to let us know the specific changes. We will 

be glad to assist you with any adjustments to your 

authorization so you won’t encounter any delays in your 

reimbursement. 

How to File for Travel Reimbursement: Reimbursement 

requests must be submitted using the enclosed Form OWCP957. Only travel costs that are directly related to 

obtaining medical treatment for your accepted condition(s) 

will be reimbursed. Receipts are required for all lodging, 

airfare, rental car (if authorized), and gasoline purchases 

(for approved rental car only). Any other expenses under 

$75.00 do not require receipts. The OWCP-957 form includes 

an instruction sheet; however, I would like to provide you 

with some additional information to help you with your 

reimbursement request: 

M&IE: Itemization of expenses and submission of 

receipts is not required for meals and incidental 

expenses (MIE). The MIE expenses are reimbursed as a 

fixed-rate, daily allowance, regardless of what you 

actually spend, and are determined by the Government 

Services Administration (GSA) published rate for the 

geographic location of your stay on any given day. 

By GSA rule, reimbursement for the first and last days 

of travel is 75% of the daily fixed-rate for MIE.

Lodging: Daily lodging rates are also based on 

applicable GSA rates for the location of your stay and 

may change due to seasonal fluctuations so be sure to 

check the current rates. State and local lodging 

taxes are not included in the daily lodging rate and 

will be reimbursed separately. All receipts must be 

SUPERSEDED

submitted.
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 7 

Page 3 of 4 

Rental Car: When a rental car has been approved, 

reimbursement will be based upon an economy-sized 

vehicle, unless otherwise approved. Gasoline 

purchases for the rental car are reimbursable. All 

receipts must be submitted. 

Airfare: Airfare reimbursement will be based upon the 

actual cost incurred, but not to exceed the cost of a 

refundable coach or economy class fare (Y-Class 

airfare). All receipts must be submitted. 

GSA Rates: The daily allowances for MIE and lodging 

are determined by GSA, for specific cities and 

geographic areas around the country, and they vary by 

region. These rates are revised occasionally by GSA. 

For more information on these GSA-published rates, 

please visit the GSA Website at: www.gsa.gov ; or 

contact your nearest resource center for assistance. 

Where to Send Your Reimbursement Forms: Send a copy of 

this authorization letter, along with your itemized Form 

OWCP-957, along with any required receipts, to our bill 

processing agent. For your convenience, I have enclosed a 

pre-paid envelope and an extra copy of this authorization 

letter. Please send your information to: 

(Insert Name and Address of the DEEOIC Bill Processing 

Agent)

Where to go for Help: For assistance in completing your 

travel reimbursement form, or in determining applicable MIE 

and lodging rates, or if you need other assistance related 

to this travel authorization or reimbursement process, 

please contact your nearest DEEOIC Resource Center, or call 

me. Below is the address of your nearest Resource Center. 

Insert complete RC address 

Telephone Number 

Additional information and forms are also available on our 

website at: https://www.dol.gov/owcp/energy/. Please have a 

safe trip and let me know if you have any other concerns 

SUPERSEDED

that are not addressed in this letter. 
FEDERAL (EEOICPA) PROCEDURE MANUAL CHAPTER 3-0300 

 Ancillary Medical Services 

Part 3 – Fiscal and Related Expenses 

___________________________________________________________ 

Exhibit 7 

Page 4 of 4 

I can be reached, toll free, at: (Insert toll free 

number). 

Sincerely, 

John Doe 

Claims Examiner 

Enc: OWCP-957 (2 blank forms) 

Prepaid envelope addressed to bill processing agent 

Copy of Authorization Letter (2 copies) 

SUPERSEDED