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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 state that Initial coverage of home oxygen therapy and oxygen equipment is reasonable and necessary 
for Groups I and II if all of the following conditions are met: 
 
   - The treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at 
the time of need; and, 
   - The beneficiary's blood gas study meets the criteria stated below; and, 
   - The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or 
supplier of laboratory services; and, 
   - The provision of oxygen and oxygen equipment in the home setting will improve the beneficiarys 
condition. 
 
Group I criteria include any of the following: 
 
   1. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest 
(awake) while breathing room air; or, 
   2. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, taken 
during sleep for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen 
saturation at or above 89 percent while awake. In this instance, oxygen and oxygen equipment is only 
reasonable and necessary during sleep; or, 
   3. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 
percent from baseline saturation, taken during sleep and associated with symptoms of hypoxemia such as 
impairment of cognitive processes and nocturnal restlessness or insomnia (not all inclusive). In this instance, 
oxygen and oxygen equipment is only reasonable and necessary during sleep; or, 
   4. An arterial PO2 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 PO2 at or above 56 mm Hg or an arterial oxygen 
saturation at or above 89 percent during the day while at rest. In this instance, portable oxygen and oxygen 
equipment is only reasonable and necessary while awake and during exercise. 
 
Group II criteria include all of the following: 
 
   A. An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent; and, 
   B. Any of the following: 
       1. Dependent edema suggesting congestive heart failure; or,        2. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, 
gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads 
II, III, or AVF); or, 
       3. Erythrocythemia with a hematocrit greater than 56 percent. 
 
A portable oxygen system is covered if the beneficiary is mobile within the home for Groups I and II, and the 
qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood 
gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary. 
 
You can find this rule in the Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment 
(L33797). 
 
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.