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HOME OXYGEN THERAPY

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    Bronchiectasis

o    Lung Cancer

o    Pulmonary hypertension

o    Erythrocytosis

o    Pneumonia

o    Asthma

o    Bronchitis

o    Bronchiolitis

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.

787-277-6653 787-474-6326