Appeal type: DME/ Orthotics
Decision: Unfavorable

It remains our decision that the Plan does not have to provide coverage for a portable oxygen concentrator.
You asked the Plan to provide coverage for a portable oxygen concentrator. You say that a portable oxygen concentrator is medically necessary. The Plan denied your request.
The Plan says Medicare coverage criteria are not met. Maximus upheld the Plans decision. You requested an ALJ hearing. The ALJ reviewing your case remanded the appeal back to Maximus stating an acknowledgment of your verbal appeal by the Plan was not in the case file and that Maximus did not respond to a request for information by the ALJ. On May 18, 2023, Maximus received a request for information from the ALJ to confirm how the case was appealed and when the Plan acknowledged that appeal. On May 19, 2023, Maximus responded to the ALJ stating the case narrative on page 4 of the case record indicates this was a verbal appeal by you to the Plan for coverage of this equipment and on page 14 of the case record is a notice sent to you by the Plan acknowledging that verbal appeal. Maximus answered the ALJ will within the 15-day period and gave specific page numbers as to where the information could be found.
Our decision remains unchanged in this case. 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 patient's skin pigmentation, the altitude level, or the patient's decreased oxygen carrying capacity, must be considered. 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 provide coverage for a portable oxygen concentrator. Our physician reviewer found a portable oxygen concentrator is considered not medically necessary because Medicare criteria are not met. The medical records show a diagnosis of dyspnea, cough, and hypoxemia. The medical record did not indicate that at the time of the appeal you were using supplemental oxygen at home. There is a physician note that states you are using your wife's oxygen at night. There is no documentation that the SpO2 can be maintained greater than 91% during activity on oxygen at 1 to 4 L/min using an oxygen conserving device. There is no documentation that a standard concentrator and portable oxygen system would not meet your needs in the home. Medicare coverage criteria for the requested equipment 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 a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to provide coverage for a portable oxygen concentrator.