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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 home oxygen is covered only when both the reasonable and necessary criteria discussed 
below, and the statutory criteria discussed in the Policy Article are met. Refer to the Policy Article for 
additional information on statutory payment policy requirements. 
 
Home oxygen therapy is reasonable and necessary only if all of the following conditions are met: 
 
    1. The treating practitioner 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 treating practitioner or by a qualified provider or 
supplier of laboratory services, and 
    4. The qualifying blood gas study was obtained under the following conditions: 
        a. 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 
        b. 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. 
 
In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test. 
 
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), or 
    2. An arterial PO2 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 PO2 at or above 56 mm Hg or an 
arterial oxygen saturation at or above 89 percent while awake, 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, 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 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 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. 
 
Initial coverage for beneficiaries meeting Group I criteria is limited to 12 months or the treating practitioner-
specified length of need, whichever is shorter. (Refer to the Certification section for information on 
recertification.) 
 
Group II criteria include the presence of: 
 
    A. An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), 
during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), 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. 
 
Initial coverage for beneficiaries meeting Group II criteria is limited to 3 months or the treating practitioner 
specified length of need, whichever is shorter. (Refer to the Certification section for information on 
recertification.) Group III includes beneficiaries with arterial PO2 levels at or above 60 mm Hg or arterial 
blood oxygen saturations at or above 90 percent. For these beneficiaries there is a rebuttable presumption of 
non-coverage. 
 
If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not 
reasonable and necessary. Oxygen therapy will also be denied as not reasonable and necessary if any of the 
following conditions are present: 
 
    1. Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen 
level in the blood and there are other preferred treatments. 
    2. Dyspnea without cor pulmonale or evidence of hypoxemia 
    3. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities 
but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the 
oxygenation of tissues with impaired circulation. 
    4. Terminal illnesses that do not affect the respiratory system 
 
You can find this rule in the Local Coverage Determination (LCD) 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.