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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 code E1392 describes an oxygen concentrator which is designed to be portable, is capable of 
delivering 85% or greater oxygen concentration, and is capable of operating on either AC or DC (e.g., auto 
accessory outlet) power. Code E1392 includes the device itself, an integrated battery or beneficiary-replaceable 
batteries that are capable of providing at least 2 hours of remote portability at a minimum of 2 LPM 
equivalency, a battery charger, an AC power adapter, a DC power adapter, and a carry bag and/or cart. The 
combined weight of the concentrator and the battery/batteries capable of 2 hours of portability must be 20 
pounds or less. If a concentrator meets all of these criteria and is also capable of functioning as a stationary 
concentrator, operating 24 hours per day, 7 days per week, the stationary concentrator code (E1390) is billed in 
addition to code E1392. You can find this rule in the Local Coverage Article A52514. 
 
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: 
 
    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 
    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 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 
    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: 
     An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest 
(awake), or 
    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 
    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 
    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.) 
 
You can find this rule int he Local Coverage Determination: Oxygen and Oxygen Equipment LCD 33797. 
 
The rules say that in reviewing the arterial PO2 levels and the arterial oxygen saturation percentages specified 
above, the Medicare Administrative Contractors (MACs) must take into account variations in oxygen 
measurements that may result from such factors as the patient's age, the patients skin pigmentation, the altitude 
level, or the patient's decreased oxygen carrying capacity. 
 
For patients who do not exhibit hypoxemia according to the above criteria, oxygen may be coverable when 
medically reasonable and necessary for patients who do not have a non-covered indication. 
 
Patients who are mobile in the home and would benefit from the use of portable oxygen in the home, may 
qualify for coverage of a portable oxygen system either by itself, or to use in addition to a stationary oxygen 
system. You can find this rule in the Social Security Act, Section 1862(a)1(A). 
 
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.