Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the portable oxygen concentrator, rental (E1392). 
 You asked the Plan to pre-approve the portable oxygen. You say that you are appealing the denial of portable 
oxygen prescribed by your doctor. You are continuously experiencing shortness of breath upon any significant 
activity. To alleviate these symptoms the doctor prescribed portable oxygen which was denied by the plan. The 
Plan denied your request. The Plan says the enrollee has refused delivery of all oxygen equipment and has not 
trialed or failed an oxygen conserving device with lightweight 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 the portable oxygen. 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 interstitial lung disease and bronchiectasis, mycobacterial lung 
infection, and rheumatoid arthritis. The enrollee was hypoxemic at rest breathing room air and oxygen has been 
prescribed.  However, the enrollee has refused a stationary concentrator and standard portable oxygen system 
and only wants a portable oxygen concentrator. There is no documentation that portable oxygen tanks would 
not meet the enrollee's needs. There is no documentation that the SPO2 (oxygen saturation) can be maintained 
greater than 91% during exercise on oxygen at 1 to 4 L/min using an oxygen conserving device. A portable 
oxygen concentrator is considered not medically necessary because Medicare criteria are not met. 
 
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 portable oxygen have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the portable oxygen concentrator, rental (E1392).