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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 to qualify for portable oxygen, the patient must meet the criteria for home oxygen. 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
03, Medicare National Coverage Determinations Manual, Section 240.2 (D). 
 
The rules say that oxygen is coverable when medically necessary for patients with acute or chronic conditions, 
short- or long- term, when the patient exhibits hypoxemia. Patients exhibiting hypoxemia are defined using the 
clinical criteria below.  
 
1. Arterial PO2 (partial pressure of oxygen) at or below 55 mm Hg or arterial O2 (oxygen) saturation at or 
below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for patients who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
In reviewing the arterial PO2 levels and the arterial oxygen saturation percentages specified above, 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, must be taken into account.  
 
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.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Sections 240.2. 
 
 OXYGEN EQUIPMENT: 
 
Initial 36 months 
 
Reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment for accessories (e.g., 
cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included in the rental 
allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance for stationary 
equipment (E0424, E0439, E1390, E1391). 
 
Payment for stationary equipment is increased for beneficiaries requiring greater than 4 liters per minute (LPM) 
of oxygen flow and decreased for beneficiaries requiring less than 1 LPM. If a beneficiary qualifies for 
additional payment for greater than 4 LPM of oxygen and also meets the requirements for portable oxygen, the 
appropriate modifiers (QB or QF) must be used. 
 
The supplier who provides oxygen equipment for the first month must continue to provide any necessary 
oxygen equipment and all related items and services through the 36-month rental period, unless one of the 
following exceptions is met: 
 
    Beneficiary relocates temporarily or permanently outside of the suppliers service area 
    Beneficiary elects to obtain oxygen from a different supplier 
    Individual case exceptions made by CMS or DME MAC 
    Item becomes subject to competitive bidding 
 
There is no further payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the 
equipment after 36 rental payments have been made. If use of portable equipment (E0431, E0433, E0434, 
E1392, K0738) begins after the use of stationary equipment begins, payment for the portable equipment can 
continue after payment for the stationary equipment ends until 36 rental payments have been made for the 
portable equipment. 
 
For information on payment for contents and maintenance, see separate sections below. 
 
The supplier who provided the equipment during the 36th rental month is required to continue to provide the 
equipment, accessories, contents (if applicable), maintenance, and repair of the oxygen equipment during the 5 
year reasonable useful lifetime of the equipment. 
 
You can find this rule 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.