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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 for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above
90%, there is a rebuttable presumption of non-coverage for home oxygen. You can find this rule in the
Medicare National Coverage Determinations Manual, Section 240.2(D)(3)(c).
The rules say that home oxygen therapy is reasonable and necessary only if all of the following conditions are
met:
1. The treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related
symptoms that might be expected to improve with oxygen therapy, and
2. The beneficiary's blood gas study meets the criteria stated below, and
3. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of
laboratory services, and
4. The qualifying blood gas study was obtained under the following conditions:
- If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the
one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
- If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must
be performed while the beneficiary is in a chronic stable state - i.e., not during a period of acute illness or
an exacerbation of their underlying disease, and
5. Alternative treatment measures have been tried or considered and deemed clinically ineffective.
The rules also say that the requested oxygen concentrator falls into the group I category. Group 1 criteria
include any of the following:
1. An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest
(awake), or
2. An arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5
minutes taken during sleep for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an
arterial oxygen saturation at or above 89 percent while awake, or
3. A decrease in arterial PO 2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5
percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g.,
impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P"
pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to
hypoxemia, or
4. An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during
exercise for a beneficiary who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen
saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during
exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during
exercise when the beneficiary was breathing room air
You can find these rules in the Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment,
L33797. This LCD is effective for services provided on or after January 1, 2019.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.