Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve portable gaseous oxygen system, rental; home 
compressor used to fill portable oxygen cylinders; includes portable containers (K0738) oxygen concentrator, 
single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow 
rate (E1390) portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, 
humidifier, cannula or mask, and tubing (E0431).  
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you are requesting 
authorization for DME oxygen and home health services. The Plan denied your request. The Plan says the 
request for a portable oxygen concentrator for possible pneumonia does not meet guideline for 
approval. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 a portable oxygen concentrator Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found supplemental oxygen is not medically necessary. It is unclear from the 
information provided whether the request is for a stationary oxygen concentrator and portable oxygen, or for a 
portable oxygen concentrator. Either way, the enrollee does not meet Medicare criteria for supplemental 
oxygen. There are no arterial blood gases or oxygen saturation data that show a need for oxygen. On June 28, 
2022 a walk test during physical therapy documented oxygen saturation 95-96% breathing room air. The denial 
is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve portable gaseous oxygen system, rental; home compressor used to fill 
portable oxygen cylinders; includes portable containers (K0738) oxygen concentrator, single delivery port, 
capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (E1390) portable 
gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, 
and tubing (E0431).