Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0203 - Oxygen and Oxygen Equipment

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and limitations of coverage and medical appropriateness: The
			 Division may cover home oxygen therapy services. Refer to Table 122-0203-1 and
			 the following guidelines:
(a) For children
			 under age 21 when the treating practitioner has determined oxygen services to
			 be medically appropriate; or
(b)
			 For adults age 21 years of age and older who are fully dual-eligible clients
			 (Medicare clients who are also eligible for Medicaid/Oregon Health Plan (OHP);
			 See definition in General Rules, OAR 410-120-0000), the Division may cover
			 oxygen services as follows:
(A) If Medicare
			 paid on the claim for the oxygen equipment, the Division may provide
			 reimbursement;
(B) If Medicare
			 denied payment on the claim for the oxygen equipment, the Division shall not
			 provide reimbursement in accordance with Medicare rules and
			 regulations;
(C) Refer to the
			 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
			 Supplemental Information for additional details on Medicare's reimbursement
			 limitation of 36 monthly rental payments;
(c) For adults 21 years of age and older who
			 are not eligible for Medicare (only eligible for Medicaid/OHP), PA is required
			 and all of the following conditions must be met:
(A) The treating practitioner has ordered and
			 evaluated the results of a qualifying blood gas study performed at the time of
			 need; and
(B) The client's blood
			 gas study meets the criteria stated below; and
(C) The qualifying blood gas study was
			 performed by a treating practitioner or by a qualified provider or supplier of
			 laboratory services; and
(D) The
			 provision of oxygen and oxygen equipment shall improve the client's
			 condition.
(d) Group I
			 criteria include any of the following:
(A) An
			 arterial partial pressure of oxygen (PO2) at or below 55 mm Hg or an arterial
			 oxygen saturation (e.g. peripheral pulse oximetry reading) at or below 88
			 percent taken at rest (awake) while breathing room air; or
(B) An arterial PO2 at or below 55 mm Hg, or
			 an arterial oxygen saturation (e.g. peripheral pulse oximetry reading) at or
			 below 88 percent, taken during sleep for a client who demonstrates an arterial
			 PO2 at or above 56 mm Hg or an arterial oxygen saturation (e.g. peripheral
			 pulse oximetry) at or above 89 percent while awake. In this instance, oxygen
			 and oxygen equipment is only necessary during sleep; or
(C) A decrease in arterial PO2 more than 10
			 mm Hg, or a decrease in arterial oxygen saturation (e.g. peripheral pulse
			 oximetry reading) 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 necessary during sleep;
			 or
(D) An arterial PO2 at or below
			 55 mm Hg or an arterial oxygen saturation (e.g. peripheral pulse oximetry
			 reading) at or below 88 percent, taken during exercise for a client who
			 demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen
			 saturation (e.g. peripheral pulse oximetry reading) at or above 89 percent
			 during the day while at rest. In this instance, portable oxygen and oxygen
			 equipment is only necessary while awake and during exercise;
(e) Group II criteria include any
			 of the following:
(A) An arterial PO2 of 56-59
			 mm Hg or an arterial blood oxygen saturation of 89 percent; and any of the
			 following:
(i) Dependent edema suggesting
			 congestive heart failure; or
(ii)
			 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
(iii) Erythrocythemia with a hematocrit
			 greater than 56 percent;
(f) Group III criteria:
(A) Initial coverage of home oxygen therapy
			 and oxygen equipment is necessary for clients in Group III if all of the
			 following conditions are met:
(i) Absence of
			 hypoxemia defined in Group I and Group II above, and
(ii) A covered medical condition with
			 distinct physiologic, cognitive, and/or functional symptoms documented in
			 high-quality, peer-reviewed literature to be improved by oxygen
			 therapy;
(g)
			 For all the sleep oximetry criteria, the five minutes does not have to be
			 continuous;
(h) When both arterial
			 blood gas (ABG) and oximetry tests have been performed on the same day under
			 the same conditions (i.e., at rest/awake, during exercise, or during sleep),
			 the ABG result will be used to determine if the coverage criteria were
			 met;
(i) If an ABG test at
			 rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same
			 day is qualifying, the oximetry test result shall determine coverage;
(j) Oxygen therapy and related services,
			 equipment or supplies are not considered medically appropriate or medically
			 necessary for any of the following:
(A) 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;
(B) Dyspnea without cor
			 pulmonale or evidence of hypoxemia;
(C) 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
			 shall improve the oxygenation of tissues with impaired circulation;
(D) Terminal illnesses that do not affect the
			 ability to breathe;
(E) Emergency
			 or stand-by oxygen systems for clients who are not regularly using oxygensince
			 these services are precautionary and not therapeutic in nature;
(F) Topical hyperbaric oxygen chambers
			 (A4575);
(G) When furnished by an
			 airline (responsibility of the client);
(H) When provided/used outside the United
			 States and its territories.