CurrentAlaska MedicaidPolicy N/A

Home Oxygen Therapy (Oxygen Equipment Order and Medical Necessity Form)

This document is an Alaska Medicaid medical necessity/certification form used to request home oxygen equipment and to document testing and clinical criteria for members aged 5 or older (separate form for under 5). It governs providers and suppliers requesting authorization for stationary or portable oxygen equipment.

Policy Summary

PayerAlaska Medicaid

PolicyHome Oxygen Therapy (Oxygen Equipment Order and Medical Necessity Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form for members aged 5 or older including test method, dates, results, and the oxygen equipment order with clinician signature certifying medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

aged 5+patient age for this form

PO2 56-59borderline threshold

Hct >56%erythrocythemia threshold

1-99 moestimated length of need

Coverage Criteria for Home Oxygen Therapy

Initial Request Criteria

Coverage supported when documentation contains required test results and, where applicable, affirmative supporting clinical findings for borderline results.

Initial request completion: Member is aged 5 or older; provider completed Sections A and C with testing method, date, and results; oxygen equipment order completed with type, LPM, and frequency; ordering clinician signature present.

Supplier must not complete Sections B–E; use Under 5 CMN if under age 5

Sufficient physiologic criteria: At least one qualifying oxygen measurement demonstrating hypoxemia (documented arterial PO2 or oxygen saturation per testing method: rest, exercise, or sleep).See thresholds module for PO2/O2 sat values

If all test results are PO2 56-59 mm Hg or O2 sat ≥89%, additional criteria below apply

Borderline result support:

Policy Summary

PayerAlaska Medicaid

PolicyHome Oxygen Therapy (Oxygen Equipment Order and Medical Necessity Form)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the form for members aged 5 or older including test method, dates, results, and the oxygen equipment order with clinician signature certifying medical necessity.

SourceLink

On This Page

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When all recorded test results are in the borderline range (arterial PO2 of 56–59 mm Hg or arterial O2 saturation of ≥ 89%), the form requires documentation of at least one supporting finding. The provider must indicate whether the member has: dependent edema suggesting congestive heart failure; pulmonary hypertension or cor pulmonale confirmed by objective testing; or erythrocythemia with hematocrit > 56%. If none of these are present, the form asks whether the member has a medical condition with distinct physiologic, cognitive, or functional symptoms expected to improve with oxygen therapy; absence of any supportive condition or symptomatic improvement means coverage is not supported per the form logic.

Key Numerical Thresholds and Form Fields

inv-04: Borderline PO2/O2 sat — arterial PO2 56-59 mm Hg or arterial O2 sat ≥ 89%

Borderline PO2/O2 saturationArterial PO2 56-59 mm Hg or arterial O2 saturation ≥ 89%

When to trigger follow-up questionsIf all entered test results meet the above borderline values, provider must answer additional clinical questions on the form

Follow-up areas queriedDependent edema suggesting CHF; pulmonary hypertension/cor pulmonale; erythrocythemia (hematocrit criteria)

inv-05: Erythrocythemia hematocrit supportive criterion — > 56%

Erythrocythemia hematocrit threshold> 56%

Where documentedListed as a follow-up supportive criterion on the form when test results are borderline

Role in coverage decisionCounts as one of the required supporting findings if all test results are borderline

inv-06: Estimated length of need field on form — 1-99 months (99 = lifetime)

Permitted values1-99 months (enter 99 to indicate lifetime)

Form field locationSection A: Est. Length of Need (1-99 Months, 99 = lifetime)

Required on initial requestOrdering clinician completes estimated length of need when submitting form

inv-12: Definition — Borderline hypoxemia triggers additional clinical questions (PO2 56-59 mm Hg or O2 sat ≥89%)

DefinitionArterial PO2 56-59 mm Hg or arterial O2 saturation ≥ 89%

Action when presentTriggers additional clinical questions about dependent edema/CHF, pulmonary hypertension/cor pulmonale, or erythrocythemia

Implication for coverageIf supportive conditions are not met and no symptomatic improvement is expected, coverage is not supported

Provider Responsibilities, Documentation, and Notices

Documentation Required

Initial Request Documentation and Signatures

Complete the Initial Request Documentation and Signatures for members aged 5 years or older using the CMN form. The form must include the testing method(s) used (rest, exercise, sleep), date(s) of test, test results (arterial PO2 in mm Hg and/or O2 saturation in %), the oxygen equipment ordered (type and LPM), frequency of use, and required provider/prescriber signatures with dates. If member is under 5, use the Under 5 CMN form.

Member and supplier identification (Member name, Medicaid ID; Supplier name, Supplier Medicaid ID)
Prescriber identification (Prescriber name, Prescriber Medicaid ID or NPI)
Date of visit addressing oxygen and requested start date
Estimated length of need (months; 99 = lifetime)
Diagnosis codes and descriptions, DOB, sex, height, weight
Method of testing: rest, exercise, and/or sleep (check all that apply)
Date of test(s) and specific results: arterial PO2 (mm Hg) and/or O2 saturation (%) — record all measured values
If results are borderline (PO2 56–59 mm Hg or O2 sat ≥ 89%), document answers to edema, pulmonary hypertension/cor pulmonale, and erythrocythemia questions, and whether the member has symptoms likely to improve with oxygen therapy
Oxygen equipment ordered: select type(s) and document LPM and frequency of use
Required signatures: ordering physician/PA/NP/specialist signature and date; specialist must sign if any part of Sections B–E was completed by someone other than the provider listed in Section B

Step Therapy

No Step Therapy Specified

The completed form does not impose any step therapy requirements. Providers are not required to trial alternative therapies or devices prior to this request under this form.

Documentation Required

Required Form Fields and Supporting Test Data

The CMN must include all of the following supporting test data and form fields to be complete: member and prescriber identification, date of visit addressing oxygen, requested start date, estimated length of need, diagnosis codes, DOB/sex/height/weight; method of testing (rest/exercise/sleep), date(s) of test, and explicit test results (arterial PO2 in mm Hg and/or O2 saturation in %). For arterial PO2 values of 56–59 mm Hg or O2 saturation ≥ 89%, the form must document dependent edema, pulmonary hypertension/cor pulmonale, and erythrocythemia status (hematocrit > 56%), and whether there is a medical condition with physiologic/cognitive/functional symptoms expected to improve with oxygen. Also include oxygen equipment ordered (type, LPM) and frequency of use.

Denial Risk

Fraud and False Statement Risk

Certification: A physician, physician assistant, nurse practitioner, or specialist who attests to medical necessity and knowingly or willfully makes or causes to be made any false statement or material omission in this Medicaid application may be prosecuted under federal and/or state law and/or be subject to civil monetary penalties or fines. By signing, the provider certifies that the information is true, accurate, and complete to the best of their knowledge and that the services/items requested are medically necessary. Understand that falsification, omission, or concealment of material facts may result in civil penalties, fines, or criminal prosecution.

Signature of Physician/Physician Assistant/Nurse Practitioner/Specialist and Date
If Sections B–E were completed by someone other than the provider listed in Section B, a specialist must sign and date the form

OpenPayer

Home Oxygen Therapy (Oxygen Equipment Order and Medical Necessity Form)

Coverage Criteria for Home Oxygen Therapy

Key Numerical Thresholds and Form Fields

Provider Responsibilities, Documentation, and Notices

Clinical Background and Test Types Collected

Terminology and Clinical Definitions