Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve portable oxygen concentrator. You say that you do not want the large home oxygen tanks because they are heavy. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you have not tried and failed use of portable oxygen tanks.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels:

1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep; 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve portable oxygen concentrator. Our reviewer says that you do not meet the Medicare criteria for the requested portable oxygen concentrator. You have been offered a stationary oxygen concentrator and portable oxygen tanks, but have refused, indicating you will only accept a portable oxygen concentrator. A portable oxygen concentrator cannot be used for nightly stationary oxygen, and most portable oxygen concentrators are not capable of providing continuous flow oxygen which you need. The medical notes do not indicate any reason why you cannot use portable tanks for mobility in the home, which has not been tried. Therefore, this portable oxygen concentrator is not medically necessary. Our physician reviewer found you have been offered a stationary oxygen concentrator and portable oxygen tanks, but have refused, indicating you will only accept a portable oxygen concentrator. A portable oxygen concentrator cannot be used for nightly stationary oxygen, and most portable oxygen concentrators are not capable of providing continuous flow oxygen which you need. The medical notes do not indicate any reason why you cannot use portable tanks for mobility in the home, which has not been tried. Therefore, this portable oxygen concentrator is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.