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Home Oxygen and Oxygen Equipment — Coverage, Authorization, and Equipment Rules
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Coverage, prior authorization, testing, and equipment rules for home oxygen therapy and oxygen equipment for Alaska Medicaid members, including initial and renewal criteria, service authorization timeframes, and equipment limitations.
Coverage criteria were revised consistent with LCD L33797 and Policy Article A52514 and took effect December 29, 2023, with a 36-month capped rental period beginning January 1, 2024.
Coverage Criteria for Home Oxygen Therapy
Initial Therapy — initial coverage of home oxygen therapy and oxygen equipment when ALL of the following are met
Initial coverage of home oxygen therapy and oxygen equipment is reasonable and necessary when ALL of the following are met:
Renewal Therapy and Authorization Timeframes — renewal and SA timeframe rules
Renewal and SA timeframe rules:
Requests that do not meet the specific coverage criteria listed in this policy will be reviewed on a case-by-case basis and may not meet coverage without additional justification. The Division applies prior authorization criteria to assess medical necessity, clinical effectiveness, and other program integrity considerations when evaluating such requests.
Initial coverage for members qualifying under Group III is limited and requires documentation that the member has a medical condition documented in high-quality, peer-reviewed literature to improve with oxygen therapy (examples include cluster headaches). Initial coverage is limited to 3 months, and conditions lacking peer-reviewed evidence of benefit will not be covered without additional supporting justification and documentation.
Coding and Clinical Thresholds
Provider Requirements and Prior Authorization
Prior Authorization Required
A service authorization (SA) is required prior to dispensing any home oxygen and oxygen equipment, except when equipment is dispensed to allow a member to discharge from the hospital. Providers must ensure the SA request and required documentation are submitted in the timeframes below.
- SA required for all home oxygen and oxygen equipment (see exceptions for discharge)
Prior Dispensing Timing
Prescriber-completed CMN for Home Oxygen and Oxygen Equipment or an electronic DME order/prescription that contains all required CMN elements must be obtained prior to dispensing, except when equipment is necessary for hospital discharge. If equipment is dispensed for discharge, the prescriber completed CMN or electronic DME order/prescription and the provider completed CMN Oxygen Supplier Page form must be submitted within ONE business day.
- Prescriber CMN OR electronic DME order/prescription required prior to dispensing (except discharge)
- If dispensed for discharge, required forms must be submitted within ONE business day
Required Forms and Supporting Documentation
Initial and renewal service authorization requests must include the specified CMN forms or an equivalent electronic DME order containing all required elements. Submit medical records supporting the prescriber CMN or electronic DME order when specifically requested or when an individual age 5+ initially qualifies under Group III with a condition not identified in that section.
- Initial SA: Completed CMN Oxygen Supplier Page + prescriber-completed CMN for Home Oxygen and Oxygen Equipment OR electronic DME order containing all CMN elements
- Renewal SA: Completed CMN Oxygen Supplier Page + prescriber-completed CMN for Home Oxygen and Oxygen Equipment Renewal Form OR electronic DME order containing all CMN elements
- Electronic DME orders may replace CMN when they include all required elements (prescriber name, ID/NPI, affiliation, member identifiers, diagnosis, length of need, face-to-face visit date, testing date/results when required, prescription frequency and liter flow, equipment order details, prescriber signature)
- Medical records should be provided when requested or for certain Group III initial qualifications
Denial Triggers
Requests that do not meet coverage criteria, are missing required forms or required elements of the CMN/electronic DME order, or are submitted outside the required timeframes may be denied. Providers must include all required documentation to avoid denial.
- Denial risk if: missing prescriber CMN or electronic DME order elements, missing CMN Oxygen Supplier Page, or SA submitted untimely
- Denial risk if qualifying blood gas or oximetry testing was not performed or does not meet coverage criteria
Clinical Group Definitions
Equipment-Specific Medical Necessity
Equipment-specific medical necessity — equipment selection and authorization must align with clinical qualifying groups and documented oxygen needs
Equipment selection and authorization must align with the member's clinical qualifying group and documented oxygen needs:
Rental, Purchase, and Capped Rental Policies
| Equipment / Category | Capped rental policy | Effective date / notes |
|---|---|---|
| Oxygen equipment (general) | Subject to a 36-month capped rental period regardless of current service authorization approvals; prior three years of reimbursements will be reviewed as part of implementation. | Capped rental period begins January 1, 2024; guidance revisions effective December 29, 2023. |
Documentation Requirements
Electronic DME orders must contain all CMN elements to substitute for paper CMN
When using an electronic DME order/prescription in place of the paper CMN, the electronic order must contain all required CMN elements listed by the policy to be accepted as equivalent.
- Required elements include prescriber name, prescriber Medicaid ID or NPI, affiliation, member identifiers (name, DOB, member ID), diagnosis codes/descriptions, length of need, date of face-to-face visit, date and results of testing (when required), prescription details (frequency of use, liter flow), equipment order (identify each system), and prescriber wet or verified electronic signature.
- An electronic order missing any required CMN element will not substitute for the prescriber-completed CMN.
Items Not Covered
Portable oxygen concentrators that do not meet the specified HCPCS E1392 component and performance requirements may not qualify for coverage or for billing as E1392. HCPCS E1392 must include the device and batteries (integrated or beneficiary-replaceable) capable of providing at least 2 hours of remote portability at a minimum of 2 LPM equivalency, a battery charger, AC and DC power adapters, and a carry bag or cart. The combined weight of the concentrator and the battery(ies) capable of this remote portability must be ≤ 20 pounds. Devices failing to meet these battery, weight, or included-component specifications may be excluded from coverage as E1392 and associated billing rules.
Background and Rationale
Home oxygen therapy is intended to correct hypoxemia and to improve physiological and symptomatic outcomes in selected respiratory and cardiac conditions. Alaska Medicaid groups members into criteria-driven categories (Group I–III) that define qualifying oxygenation thresholds and clinical circumstances for initial and renewal coverage, and applies prior authorization to ensure oxygen provision in the home setting will improve the member’s condition.
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