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 a portable oxygen concentrator. You say that you occasionally fly to visit 
family and gas tanks are not allowed on airplanes, portable concentrators are. One tank does not usually last 
long enough for some trips out of the house. The Plan denied your request. The Plan says a portable oxygen 
concentrator is not covered for the purposes of travel and is contraindicated for use with a continuous positive 
airway pressure (CPAP)/bilevel positive airway pressure (BiPAP). 
 
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 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 a portable oxygen concentrator is not medically necessary because 
Medicare criteria are not met. This enrollee has complex sleep apnea and pulmonary hypertension and has been 
on continuous oxygen therapy for years. The enrollee has BiPAP at night. The enrollee is requesting a portable 
oxygen concentrator for air travel and other travel outside the home. This is considered a convenience by 
Medicare, which does not cover a portable oxygen concentrator for travel outside the home. In addition, there 
is no documentation that the oxygen saturation (SpO2) can be maintained above 91% during activity using an 
oxygen conserving device at 1 to 4 liters per min. 
 
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 a portable oxygen concentrator (E1392).