Description: |
Through the process of extracting the oxygen from the room air, these electrically powered machines can deliver oxygen to patients at home. They are relatively quiet and extremely efficient. Oxygen concentrators are maintained through scheduled preventive maintenance evaluations. |
Medicare's Medical Coverage Criteria: |
Platinum 5 Oxygen Concentrator
Home Oxygen is covered by Medicare only if all of the following conditions are met:
1.) The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and
2.) The patient’s blood gas study meets the criteria stated below, and
3.) The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
4.) The qualifying blood gas study was obtained under the following conditions:
*If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
*If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the patient is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
5.) Alternative treatment measures have been tried or considered and deemed clinically ineffective.
Group I: criteria include any of the following:
- An arterial P02 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
- An arterial P02 at or below 55 mm Ht, or an arterial oxygen saturation at or below 88 percent, taken during sleep for a patient who demonstrates an arterial P02 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake, or
- A decrease in arterial P02 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, “P” pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), or
- An arterial P02 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter.
Group II: criteria include the presence of (a) an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep, or during exercise (as described under Group I criteria) and (b) any of the following:
- Dependent edema suggesting congestive heart failure, or
- Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
- Erythrocythemia with a hematocrit greater than 56 percent.
Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Documentation section for information on recertification.)
Group III: includes patients with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these patients there is a rebuttable presumption of noncoverage.
If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not medically necessary. Oxygen therapy will also be denied as not medically necessary if any of the following conditions are present:
- 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 that impaired circulation.
- Terminal illnesses that do not affect the respiratory system.
The qualifying blood gas study must be performed by a physician or by a qualified Medicare Part A provider or a qualified laboratory. A supplier is not considered a qualified provider or a qualified laboratory for purposes of this policy. In addition, the qualifying blood gas study may not be paid for by any supplier. This prohibition does not extend to blood gas studies performed by a hospital certified to do such tests.
The qualified blood gas study may be preformed while the patient is on oxygen as long as the reported blood gas values meet the Group I or Group II criteria.