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Physicians Order Form *requires MS Word |
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Covered by Medicare for patients with significant hypoxemia in the chronic stable state. If patient is diagnosed with either a severe primary lung disease, such as:
- Chronic obstructive pulmonary disease
- Diffuse interstitial lung disease
- Cystic fibrosis
- Bronchiectasis, or
- Widespread pulmonary neoplasm
- Or, if the patient is diagnosed with hypoxia-related symptoms that may improve with oxygen therapy, such as:
- Pulmonary hypertension
- Recurring congestive heart failure due to chronic cor pulmonale
- Erthrocytosis
Provided the following conditions are met:
- the attending physician has determined that the patient has a severe lung disease of hypoxia-related symptoms that might be expected to improve with oxygen therapy,
- the patient's blood as levels indicate the need for oxygen therapy, and
- alternative treatment measures have been tried or considered and deemed clinically ineffective.
A physician's written CMN is required and the CMN must specify:
- diagnosis of the disease requiring oxygen therapy (see above)
- the flow oxygen flow rate (e.g., 2 liters per minute)
- the frequency and duration of oxygen use (e.g., 10 minutes per hour, 12 hours per day)
- the duration of oxygen need (e.g., 4-12 months or lifetime).
These are three basic groups of values for ABGs and O2 saturation that will determine coverage.
| Group I: | Arterial Blood Gas (PO2) is less than or equal to 55 mm Hg or the O2 Sat is less than or equal to 88% (awake and at rest). If a patient has higher levels, but demonstrates desaturation to these levels during sleep or exercise, then oxygen may be reimbursed. Also, if during sleep, the levels are higher than 55 mm Hg or saturation higher than 88%, but represent a drop of 10 mm Hg (ABGs) or 5% (O2 Sat) from awake, at rest levels, and are associated with demonstrated cor pulmonale, pulmonary hypertension and erythrocytosis, the patient may qualify. |
| Group II: | If the Arterial Blood Gas (PO2) is 55-59 mm Hg or the O2 Sat is 89% (awake and at rest) - covered if:
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| Group III: | If the Arterial Blood Gas (PO2) is 60 mm Hg or greater or the O2 Sat is 90% or greater, Medicare will not reimburse supplemental oxygen, since according to these results the patient is not truly hypoxemic, and supplemental oxygen is not considered medically necessary. |
Initial Certification: Group I and II patients must be tested within 30 days prior to the date of initial certification. This would be for patients that have already been discharged from the hospital or within two days prior to discharge from an inpatient facility to home.
Recertification: Group I patients with a prescribed length of need of less than lifetime are required to be re-tested within 30 days prior to recertification. Group II patients must be tested between the 61st and 90th day after the date of initial certification.
Physician Evaluation
Initial Certification: Group I and II patients must be seen and evaluated within 30 days prior to the date of initial certification.
Recertifications: Group I and II patients must be seen and re-evaluated within 90 days prior to the recertification date.
Patient's Arterial Blood Gas test (PO2) or oxygen saturation test (SaO2) must be performed with the patient in a chronic stable state as an outpatient OR within two (2) days prior to discharge from an inpatient facility to home.
If oxygen therapy coverage is approved, the coverage applies regardless of delivery system chosen. If coverage is approved, any equipment and supplies necessary to the patient's use of covered home oxygen therapy, like regulators (flowmeters), humidifiers and face masks are also covered. Back-up oxygen tanks are not covered. Supplies are not separately reimbursable unless the equipment is owned by the patient.