Kaiser Foundation Health Plan of Washington Clinical Review Criteria
Clinical review criteria governing medical necessity determinations and coverage for home oxygen therapy and related oxygen equipment for Kaiser Foundation Health Plan of Washington members, referencing Medicare coverage manuals and MCG guidelines for non-Medicare members.
03/01/2022 - Updated applicable codes
Coverage Summary
This policy (KP-0343) covers clinical review criteria for Home Oxygen and Oxygen Equipment (Home Oxygen) and governs medical necessity determinations and coverage for Kaiser Foundation Health Plan of Washington members. The policy status is CURRENT and the coverage stance is covered_with_criteria. Effective date: 1985-12-15; Last review: 2024-02-13. For Medicare members, coverage follows Medicare sources including the CMS Claims Processing Manual Chapter 20 Section 30.6 and NCD Home-Use of Oxygen (240.2); for non-Medicare members Kaiser Permanente uses the MCG (Milliman Care Guidelines) Home Oxygen guideline as the primary non-Medicare criteria source. Policy number: KP-0343.
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