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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that only a stationary gaseous oxygen system (E0424) and related contents (E0441) are covered 
for the treatment of cluster headaches for beneficiaries enrolled in a clinical trial approved by CMS which are 
in compliance with the requirements described in the CMS National Coverage Determination Manual (Internet 
Only Manual 100-03) 240.2.2 for dates of service on or after 01/04/2011. This section states, in part: Only 
those beneficiaries diagnosed with the condition of cluster headache are eligible for participation in a clinical 
study. CMS adopts the diagnostic criteria used by the International Headache Society to form a definitive 
diagnosis of CH. Therefore, the home use of oxygen to treat CH is covered by Medicare only when furnished 
to Medicare beneficiaries who have had at least five severe to very severe unilateral headache attacks lasting 
15-180 minutes when untreated. (Intensity of pain: Degree of pain usually expressed in terms of its functional 
consequence and scored on a verbal 5-point scale: 0=no pain; 1=mild pain, does not interfere with usual 
activities; 2=moderate pain, inhibits but does not wholly prevent usual activities; 3=severe pain, prevents all 
activities; 4=very severe pain. It may also be expressed on a visual analogue scale.) 
 
The headaches must be accompanied by at least one of the following findings: 
 
    1. Ipsilateral conjunctival injection and/or lacrimation; or 
    2. Ipsilateral nasal congestion and/or rhinorrhea; or 
    3. Ipsilateral eyelid edema; or 
   4. Ipsilateral forehead and facial sweating; or 
    5. Ipsilateral miosis and/or ptosis; or 
   6. A sense of restlessness or agitation 
 
Claims for oxygen equipment not meeting the criteria above will be denied as not reasonable and necessary. 
 
Claims for stationary oxygen equipment other than E0424 and all portable oxygen equipment used for cluster 
headaches will be denied as not reasonable and necessary. 
 
Claims for E0424 and E0441 used to treat cluster headaches follow the same payment rules for all other 
covered oxygen equipment. Refer to the related Policy Article for information on statutory payment rules and 
coding guidelines to be used for these claims. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Oxygen and Oxygen 
Equipment (L33797). 
 
The rules say that reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment for 
accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included in 
the rental allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance for 
stationary equipment (E0424, E0439, E1390, E1391). You can find this information in Medicare's Local 
Coverage Article: Oxygen and Oxygen Equipment - Policy Article (A52514). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.