Home oxygen therapy is covered by Medicare in the United States if the patient meets certain requirements.
Requirements:
(1) The patient has been diagnosed with a condition proven to benefit from supplemental home oxygen therapy
(1a) chronic lung disease (COPD, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, diffuse pulmonary neoplasm) OR
(1b) hypoxic condition such as pulmonary hypertension, congestive heart failure, erythrocytosis
(2) Quantitative measurement meet one or more criteria listed in the table below on more than one occasion/
(3) The patient is receiving optimum management.
|
Measurement |
Situation |
Special Note |
|
PaO2 on room air < 55 mm Hg |
at rest |
|
|
arterial oxygen saturation < 88% |
at rest |
|
|
PaO2 on room air < 55 mm Hg |
during sleep |
coverage only during sleep; does not cover portable oxygen |
|
arterial oxygen saturation < 88% |
during sleep |
coverage only during sleep; does not cover portable oxygen |
|
significant drop in PaO2 during sleep (> 10 mm Hg) plus signs of hypoxemia |
during sleep |
coverage only during sleep; does not cover portable oxygen |
|
significant drop in arterial oxygen saturation (> 5%) plus signs of hypoxemia |
during sleep |
coverage only during sleep; does not cover portable oxygen |
|
PaO2 on room air < 55 mm Hg |
during exercise |
coverage only during exercise |
|
arterial oxygen saturation < 88% |
during exercise |
coverage only during exercise |
|
PaO2 56 to 59 mm Hg |
congestive heart failure (CHF) |
|
|
arterial oxygen saturation <= 89% |
congestive heart failure (CHF) |
|
|
PaO2 56 to 59 mm Hg |
pulmonary hypertension or cor pulmonale |
|
|
arterial oxygen saturation <= 89% |
pulmonary hypertension or cor pulmonale |
|
|
PaO2 56 to 59 mm Hg |
hematocrit > 56% (erythrocythemia) |
|
|
arterial oxygen saturation <= 89% |
hematocrit > 56% (erythrocythemia) |
|
where:
• Signs of hypoxemia during sleep may include insomnia, nocturnal restlessness, morning headache and/or impaired cognitive processes.
• Clinical evidence of congestive heart failure includes dependent edema.
• Pulmonary hypertension or cor pulmonale may be documented by directly measured pulmonary artery pressure, gated blood pool scan, echocardiogram or ECG changes.
Coverage of additional conditions may be petitioned. The reviewing physician will take into account:
(1) the diagnosis
(2) the patient's age
(3) the patient's altitude
(4) conditions impacting the patient's blood oxygen carrying capacity
Purpose: To determine if a patient meets the Medicare requirements for reimbursement of home oxygen therapy.
Specialty: Pulmonology, Pharmacology, clinical
Objective: selection
ICD-10: R09.0,
