Oxygen Coverage

 
Note:  The following coverage criteria is for Medicare, other insurances may have different criteria and may be less stringent.  In most cases, meeting Medicare criteria will meet all other criteria’s.

• A written signed and dated prescription prior to dispensing is required before Oxygen can be dispensed.
• All criteria shown below must be met for coverage.
• The face to face notes must include the conditions for coverage  as described below (these must be completed and signed prior to dispensing the item):

GROUP 1

1. Patient has a severe lung disease or hypoxia related symptoms that might improve with therapy.

• COPD, diffuse interstitial lung disease, bronchiectasis, cystic fibrosis.
• Hypoxia related symptoms such as pulmonary hypertension, recurring CHF due to chronic cor pulmonale, erythrocytosis, impairment of cognitive process, nocturnal restlessness and morning headache.
• Hypoxemia alone will not be covered.  There needs to be an underlying condition causing the hypoxemia.
• Non-covered conditions:  angina pectoris in absence of hypoxemia, breathlessness without cor pulmonale or hypoxemia sever peripheral vascular disease, terminal illness that do not affect lungs, pneumonia, angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments.  Dyspnea without cor pulmonale or evidence of hypoxemia. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.  Terminal illnesses that do not affect the respiratory system.

2. Blood gas or Saturation study meets criteria indicated below:
   • Method I:  On room air at rest while awake, oxygen saturation equal to or less than 88 % or PaO2 equal to or less than 55 mmhg.
   • Method II:  If during exercise the following tests must be documented:
     1. Oxygen saturation on room air at rest – should be above 88%
     2. Oxygen saturation on room air with exercise – needs to be equal to or less than 88%
     3. Oxygen saturation on oxygen with exercise – shows improvement with oxygen

NOTE:  If patient qualifies with Method II, then whoever does the testing must provide and document all 3 test results described above, including the liter flow tested at in iii.  If all 3 are not performed and documented, the oxygen will not be covered.

• Method III:  During sleep on room air the oxygen saturation is equal to or less that 88% for at least 5 minutes and does not have to be continuous.

3. Alternative treatment measures, such as inhalers or nebulizer treatments, have been tried or considered, and ruled out or is clinically ineffective.  This must be documented in the face to face notes.

Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-Specified length of need, whichever is shorter.
GROUP 2

• Blood gas study with PaO2 of 56-59 mmhg or oxygen saturation of 89% at rest, while awake, curing sleep for 5 minutes or during exercise as described under GROUP 1 above, and
  1. Dependent edema suggesting CHYF, OR
  2. Pulmonary hypertension or cor pulmonale determined by measurement of pulmonary artery pressure, echocardiogram, or “P” pulmonale on EKG, OR
  3. Erythrocythemia with hematocrit great than 56%

For Group 1 and Group 2, there must be evidence of an in person face to face visit with the treating practitioner performed within 30 days before the initial set up.
BLOOD GAS AND SATURATION STUDY:

1. Performed by a physician, qualified provider, or laboratory service that can bill Medicare such as an IDTF, and
2. Study must have been performed within 30 days of initial certification while patient is in a chronic stable state, OR during and inpatient hospital stay and done within 2 days prior to discharge.
3. If the testing was performed in an emergency room, then it is considered and acute situation and would not be considered as acceptable for coverage.

LITER FLOW GREATER THAN 4 LPM:
If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 LPM will be paid only if a blood gas study is performed while the beneficiary is on 4 or more LPM and meets Group 1 or Group 2 criteria.  If a flow rate of greater than 4 LPM is billed and the criteria for the higher allowance is not met, payment will be limited to the standard fee schedule allowance.
OTHER NOTES:

1. If portable oxygen is ordered, there needs to be documentation in the medical records indicating the patient is mobile within the home.
2. Portable oxygen is considered when the blood gas or saturation study is performed while patient is awake or with exercise.  At night use only does not qualify for a portable unit.
3. A frequency of use must be indicated, i.e.: 2 LPM continuous or 3 LPM at night.  PRN or as needed order are not covered by Medicare.
4. HME suppliers are not considered qualified to perform blood gas or saturation studies for qualification.

DETAILED WRITTEN ORDER (DWO) must contain the following:

1. Beneficiary’s name
2. Date of order
3. Detailed description of the item being ordered
4. Route of administration
5. Frequency of use
6. Length of need
7. Treating Practitioner’s printed name and NPI
8. Treating Practitioners signature and date

The CMN can be the DWO if it contains all of the above information.
OXYGEN WITH PAP DEVICE:
For patients requiring the use of home oxygen with PAP device, both the PAP and oxygen policies must be met. The qualifying blood gas study must be performed during a titration study at a sleep lab facility making sure the pressure is at an optimal setting.  The oximetry study performed during this titration shows oxygen saturation of 88 % or less for 5 total minutes (does not have to be continuous). There has to be a reduction in AHI/RDI reduced to less than or equal to an average of 10 events/hours, or if the initial AHI/RDI was less than an average of 10 events per hour, then the titration demonstrates further reduction in AHI/RDI.
RECERTIFICATION:

1. The following to be obtained with the recertification CMN for either Group I or Group 2:
   Re-evaluation by treating physician documenting patient is benefiting from the
   oxygen therapy and has shown improvement.
2. Copy of most recent blood gas study (can be from the initial test, if that is the
   most recent) BUT should not be the normal practice.
3. 
   GROUP 1 = Required after 12 months of initial certification, which means the
   re-evaluation most occur within 90 days prior to the date of recertification.
   GROUP 2 = Required after 3 months of initial certification, which means the
   re-evaluation must occur between the 61st-90th day following the initial date.