Stationary oxygen equipment and home oxygen therapy are covered for payment when the following criteria is met:
· At least one of the following diagnosis:
o Chronic obstructive pulmonary disease
o Cystic Fibrosis
o Lung Cancer
o Pulmonary hypertension
o Recurring congestive heart failure due to cor pulmonale
· For cluster headache diagnosis when other therapies have failed.
· Hypoxemia evidence by any combination of the following clinical findings and oxygenation results (taken at room air unless medically contraindicated):
o PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% at rest.
o PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% for at least 5 minutes taken during sleep for a person with a PO2 ≥ 56 mm Hg or arterial oxygen saturation ≥ 89% awake.
o A decrease of more than 10 mm Hg in arterial PO2, or a reduction in arterial oxygen saturation for more than 5% for at least 5 minutes of sleep
o Decrease in arterial PO2 of more than 10 mm Hg or a decrease in arterial oxygen saturation more than 5% for at least 5 minutes taken during sleep associated with symptoms or signs attributable to hypoxemia including, but not limited to, cor pulmonale, “P” pulmonale on electrocardiogram [EKG], pulmonary hypertension, and erythrocytosis.
o Arterial PO2 ≤ 55-59 mm Hg or or arterial oxygen saturation ≤ 89% at rest, for at least 5 minutes during sleep or during exercise (as described in the first bullet) and one of the following:
§ Dependent edema associated with congestive heart failure
§ Pulmonary hypertension, chronic cor pulmonale or congestive heart failure with hypoxemia
§ Erythrocythemia with a hematocrit greater than 56%
Portable oxygen systems are covered for payment when criteria for stationary oxygen necessity is met and the patient is mobile within the home.
Portable oxygen concentrators and combinations of stationary/portable oxygen systems are covered for payment when the above criteria are met, and the
patient is active and frequently exceeds the time limitations in conventional ambulatory oxygen systems.