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    v1.0.28
    OpenPayerPolicy UpdatesPulmonologyHighmark Blueshield Neny Oxygen CMN Coverage | Ope…
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    CurrentHighmark Blueshield NenyPolicy N/A

    Certificate of Medical Necessity (CMN) for Oxygen Therapy — Coverage Criteria

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    This document is a CMN form that governs documentation and clinical data required to establish medical necessity for home oxygen therapy for patients, intended for providers ordering oxygen equipment and services.

    Policy Summary
    PayerHighmark Blueshield Neny
    PolicyCertificate of Medical Necessity (CMN) for Oxygen Therapy — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewJun 28, 2011
    Next Review DateN/A
    Key ActionSubmit a room-air ABG PO2 or oxygen saturation performed within 30 days plus a typed office note and physician signature.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    30 daysTest recency
    >=56-59 / >=89%Borderline threshold
    06/28/2011Revision

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Physician requiredSignature

    Coverage Criteria for Home Oxygen Therapy

    Documentation and clinical evidence required

    Coverage supported when required objective testing and documentation are provided:

    Core documentation: Arterial blood gas (PO2) or oxygen saturation performed on room air within 30 days; typed office note with pertinent information; lab results if available; physician signature (stamps not acceptable)PO2/O2 sat on room air within 30 days

    Physician/provider performing the test cannot be a DME or respiratory equipment provider

    Clinical considerations: Documentation that disease is severe and will improve with therapy; patient was in a chronic stable state at time of testing; alternatives to improve cardiopulmonary function were considered/tried and documented as ineffectiveyes/no fields on form

    Form includes fields to indicate these items

    Supportive qualifying conditions for borderline values: If PO2 >= 56-59 mm Hg or oxygen saturation >= 89%, presence of dependent edema from congestive heart failure, cor pulmonale or pulmonary hypertension (documented by diagnostic testing), hematocrit >56%, or other documented condition may help qualifyPO2 >= 56-59 mm Hg or O2 sat >= 89%

    Complete supporting condition fields on form and provide diagnostic documentation for cor pulmonale/pulmonary hypertension

    Prescription specifics: Specify equipment type requested (stationary, portable, or both) and the highest ordered flow in LPM; if prescribed flow > 4 LPM, provide recent test results obtained while the patient was on 4 LPM (date and PO2 or O2 saturation on 4 LPM)flow documented; if >4 LPM then 4 LPM test results

    Form requests dates and results when testing on supplemental O2; patient mobility questions for portable equipment

    The CMN requires that the physician or provider who performs the oxygenation test not be a DME or respiratory equipment provider. This restriction follows Medicare guidance and is captured on the form where the testing clinician is identified and the statement “Cannot be a DME or Respiratory Equipment Provider” is required.

    The CMN specifically requires an arterial blood gas (PO2) or oxygen saturation measured on room air within 30 days of the request. If that room‑air measurement is absent, or if documentation does not confirm the patient was in a chronically stable state at the time of testing (as asked on the form), the CMN does not meet the stated requirements and coverage is jeopardized.

    Testing Thresholds and Coding-related Values

    Arterial PO2 / Oxygen saturation thresholds — key requirements
    Timing and conditions for testArterial PO2 or oxygen saturation must be performed on room air and within 30 days of the request.
    Borderline values that trigger additional reviewIf PO2 is >= 56–59 mm Hg or oxygen saturation is >= 89%, complete additional qualification questions.
    Testing when >4 LPM prescribedIf the highest ordered flow is >4 LPM, provide recent test results performed while the patient is receiving 4 LPM (form requests dates and results).
    Provider performing testThe physician/provider performing the test cannot be a DME or respiratory equipment provider (per Medicare).

    Provider Responsibilities and Required Documentation

    Prior Authorization

    Prescription and testing details required

    Provide a complete, signed prescription and recent oxygenation test results with the request. The prescription must specify equipment type (stationary, portable, or both) and the highest ordered flow in LPM. If the ordered flow is >4 LPM, include recent test results obtained while the patient was on 4 LPM.

    • Specify equipment requested: Stationary only, Portable only (include mobility within home), or Both (stationary + portable).
    • Record highest ordered flow (LPM).
    • If prescribed flow >4 LPM, include date and results of test performed on 4 LPM: ABG PO2 (mm Hg) and/or oxygen saturation (%).
    • Physician signature required on prescription (stamps not acceptable).
    Denial Risk

    Recent oxygenation test required

    A recent (within 30 days) oxygenation measurement performed on room air is required. Acceptable tests are arterial blood gas (ABG) PO2 or oxygen saturation (pulse oximetry) measured on room air. Missing this test will likely result in denial or an incomplete CMN.

    Background

    The CMN collects objective measures of hypoxemia — specifically an arterial PO2 or oxygen saturation performed on room air — to determine eligibility for long‑term oxygen therapy. The form requires the date and result of the most recent assessment (must be within 30 days), documentation of test conditions and stability at the time of testing, and supporting items such as a typed office note and lab results.

    Definitions and Supportive Conditions

    Room‑air test (definition and documentation)
    Definition of room‑air testAn arterial blood gas (PO2) or oxygen saturation measurement performed while the patient is breathing room air and within 30 days of the request.
    Test conditions to documentSpecify whether measurement was at rest, during activities of daily living, during exercise, or during sleep (automated oximetry), and that the patient was in a chronic stable state at time of testing.
    Required documentation elementsRecord date of most recent assessment and the measured Arterial PO2 (mm Hg) or oxygen saturation (%) on the form.
    Supportive qualifying conditions for borderline oxygenation values
    Dependent edema due to congestive heart failureListed as a supportive qualifying condition to help qualify the patient when PO2 is in the borderline range.
    Cor pulmonale or pulmonary hypertension
    Policy Summary
    PayerHighmark Blueshield Neny
    PolicyCertificate of Medical Necessity (CMN) for Oxygen Therapy — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewJun 28, 2011
    Next Review DateN/A
    Key ActionSubmit a room-air ABG PO2 or oxygen saturation performed within 30 days plus a typed office note and physician signature.
    SourceLink
    On This Page
    Coverage Criteria for Home Oxygen TherapyTesting Thresholds and Coding-related ValuesProvider Responsibilities and Required DocumentationBackgroundDefinitions and Supportive Conditions
    • ABG PO2 (mm Hg) or oxygen saturation (%) must be performed on room air within 30 days of the request.
    • Document whether test was taken at rest, during activity, exercise, or sleep as applicable.
    Denial Risk

    Incomplete prescription information — risk of denial

    Ensure the prescription includes all requested details and is fully executed. Omitted information or unacceptable signatures increase risk of denial or processing delay.

    • Physician signature required; stamps are not acceptable.
    • Include contact name and phone number for ordering provider.
    • Complete prescription fields: equipment type, mobility status (if portable), highest flow (LPM), and duration (months/years on therapy).
    Documentation Required

    Required clinical documentation

    Submit required clinical documentation along with the CMN to support medical necessity. Include the typed office note, pertinent lab results, and documentation of test conditions.

    • Typed office note with relevant clinical history and rationale for oxygen therapy.
    • Lab results (ABG, oximetry) if available.
    • Name of physician/provider who performed the test (must not be the DME supplier).
    • Indicate whether patient was in a chronic stable state at time of testing and the test conditions (rest, activity, exercise, sleep).
    Documentation Required

    Alternatives documented

    Document prior treatments and alternatives that were considered or tried and were ineffective before initiating long-term oxygen therapy.

    • State which alternative treatment measures to improve cardiopulmonary function were attempted and the results.
    • Confirm alternatives were considered and documented as ineffective in the office note.
    Listed as a supportive qualifying condition — documentation by diagnostic testing is requested.
    Hematocrit > 56%Hematocrit greater than 56% is included as a supportive qualifying condition for borderline oxygenation values.
    Other documented conditionsThe form allows selection of other conditions that may help qualify the patient when PO2/O2 saturation values are borderline.