Appeal type: unknown
Decision: unknown

 
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 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. 
 
If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary 
system. See exception in the LCD-related Policy Article Non-Medical Necessity Coverage and Payment Rules, 
OXYGEN EQUIPMENT, Initial 36-Months section. 
 
If a portable oxygen system is covered, the supplier must provide whatever quantity of oxygen the beneficiary 
uses; Medicares reimbursement is the same, regardless of the quantity of oxygen dispensed. 
 
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 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 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
You can find this information in the Local Coverage Oxygen and Oxygen Equipment - Policy Article 
(L33797).