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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 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. 
Time of need is defined as during the patients illness when the presumption is that the provision of oxygen 
will improve the patients condition in the home setting. For an inpatient hospital patient anticipated to require 
oxygen upon going home, the time of need would be within 2 days of discharge. 
 
Group I criteria include any of the following: 
An arterial partial pressure of oxygen (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, 
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, 
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, 
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: 
An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent; and, 
Any of the following: 
Dependent edema suggesting congestive heart failure; or, 
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, 
Erythrocythemia with a hematocrit greater than 56 percent. 
 
Group III criteria: 
Initial coverage of home oxygen therapy and oxygen equipment is reasonable and necessary for beneficiaries in  
 
Group III, if all of the following conditions are met: 
Absence of hypoxemia defined in Group I and Group II above; and, 
A medical condition with distinct physiologic, cognitive, and/or functional symptoms documented in high-
quality, peer-reviewed literature to be improved by oxygen therapy, such as cluster headaches (not all 
inclusive). 
If all of the coverage conditions specified above for initial claims for beneficiaries in Groups I, II and III, or 
documentation requirements for continued payment of subsequent claims are not met, the oxygen therapy and 
oxygen equipment will be denied as not reasonable and necessary. Please refer to the LCD-related Policy 
Article (A52514) for additional information regarding documentation requirements necessary for continued 
payment of oxygen and oxygen equipment claims. 
 
Group IV criteria: 
Oxygen therapy and oxygen equipment will also be denied as not reasonable and necessary if any of the 
following conditions are present: 
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; or, 
Dyspnea without cor pulmonale or evidence of hypoxemia; or, 
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; or, 
Terminal illnesses that do not affect the ability to breathe. 
You can find these rules in the Local Coverage Determination (LCD) Oxygen and Oxygen Equipment L33797. 
 
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. 
 
RELOCATION and TRAVEL: 
 
Months 1 through 36 
 
If the beneficiary relocates outside the suppliers service area (either short-term travel, extended temporary 
relocation, or permanent relocation), then for the remainder of the rental month for which it billed, the home 
supplier is required to provide the equipment and related items/service itself or make arrangements with a different supplier to provide the equipment, items, and services. For subsequent rental months that the 
beneficiary is outside the service area, the home supplier is encouraged to either provide the equipment and 
related items/services itself or assist the beneficiary in finding another supplier in the new location. The home 
supplier may not bill for or be reimbursed by Medicare if it is not providing oxygen equipment or has not made 
arrangements with a different supplier to provide the equipment on the anniversary billing date. Medicare will 
pay only one supplier to provide oxygen during any one-rental month. 
 
Months 37 through 60 
 
If the beneficiary relocates outside the suppliers service area (either short-term travel, extended temporary 
relocation, or permanent relocation), the home supplier is required to either provide the equipment and related 
items/services itself or make arrangements with a different supplier to provide the equipment and related 
items/services. You can find these rules in the Local Coverage Article Oxygen and Oxygen Equipment - Policy 
Article A52514. 
 
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.