Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the oxygen equipment. You say that the current device stopped working and 
it needs servicing. But since you switched Plans, you cannot get it serviced. You were recently hospitalized and 
have follow up appointments but cannot go due to a non-functional portable concentrator. The Plan denied your 
request. The Plan says there is no indication the enrollee's current oxygen equipment is not meeting their 
medical needs. 
 
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 the oxygen equipment. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has chronic obstructive pulmonary disease (COPD), obstructive sleep 
apnea on continuous positive airway pressure (CPAP), and severe pulmonary hypertension.  The enrollee was 
recently hospitalized for an exacerbation of heart failure.  The enrollee is on home oxygen with a stationary 
concentrator.  It is unclear whether the enrollee has a portable oxygen system.  There is no documentation that 
a standard portable oxygen system would not meet the enrollees needs for mobility within the home.  There is 
no documentation that oxygen saturation (SpO2) can be maintained above 91% during activity using an oxygen 
conserving device at a flow rate of 1 to 4 liters per minute. A 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 the oxygen equipment have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable oxygen concentrator (E1392).