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Medicare Oxygen Coverage Guidelines

Laboratory Result	Action
Group I: PaO2 at or below 55mm Hg or SaO2 at or below 88% (awake and at rest)	Acceptable for Medicare Coverage. Note: May be covered for nocturnal use only if: * Levels are higher than noted, but drop to Group I levels during sleep, OR * Levels are higher than noted, but during sleep drop > 10mm HG (ABGs) or > 5% (O2 Sat) from awake/at rest levels, AND are associated with demonstrated cor pulmonale, pulmonary hypertension and erythrocytosis. Note: May be covered for exercise only if: * Levels are higher than noted, but drop to Group I levels during exercise and it can be documented that supplemental oxygen improves the hypoxemia demonstrated during exercise on room air.
Group II: PaO2 = 56-59mm Hg or SaO2 = 89% (awake and at rest)	Requires Documentation of: * 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 of EKG (P wave >3mm in standard leads II, III or AVF) OR * Erthrocythermia with Hct > 56%
Use CMN DMERC Form 484.2. Recertification required 12 months after initial CMN if the patient starts out with Group I blood gas levels (submit most recent available ABG or O2 Sat.) Recertification required within 90 days if the initial levels fall into Group II (submit repeat ABG or O2 sat) performed between 61st and 90th day. Recertfication also due at the expiration of a period of estimated medical need. Revised CMN required with change in prescription or change in ordering physician.
Group III: PaO2 at or above 60mm Hg or SaO2 at or above 90%	* Presumes not medically necessary * Extensive physician documentation required for approval.
Demonstration of hypoxemia is accomplished by either arterial blood gases (ABGs) or measurement of oxygen saturation (O2 Sat.) If both tests are available, ABGs should be submitted with CMN. It is no longer necessary that tests be performed with the patient on room air only. Tests should be done while patient is already in a chronic stable state as an outpatient or within two calendar days before hospital discharge.
Portable Oxygen Requirements
Medicare coverage of a portable oxygen system, alone or to complement a stationary oxygen system, may be allowed if the patient is mobile within the home.
Oxygen CMN - Physician Information (Section B, DMERC Form 484.2)
Questions #1 & #7	This should be the most recent test or prior to the most recent date at the top of Section A. If both ABG and SaO2 tests are performed on that same day, only report PaO2. If the patient's levels are low enough to qualify for Medicare coverage while breathing supplemental oxygen, then test in Question #1 may be performed with patient on oxygen. However, titrate the flow down to a level where Medicare criteria are clearly met. (If criteria are not met, provide additional information justifying medical necessity.)
Questions #2	If the answer is "no", provide additional information justifying medical necessity.
Questions #4	Medicare does not accept a test performed by the oxygen supplier (except when the supplier is a hospital-owned company and the test is performed by the hospital.)
Questions #6	If different flow rates are prescribed for different situations (e.g. at rest, during exercise, during sleep), enter the highest value in this question. Other values can be noted in Section C.
Questions #7	Leave blank if the prescribed flow rate in question #6 is less than or equal 4LPM.
Questions #8-10	Circle "Y" or "N" if reported results in Question #1 show a PaO2 greater than 55mm Hg or an SaO2 greater than 88%. Otherwise, circle "D" for "does not apply."
Note: The information contained in Section C, along with the answer to Question #6 in Section B, can serve as the physician's order.

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