CurrentnorthwoodPolicy N/A

Oxygen and Oxygen Equipment (Medicaid) - Coverage Criteria

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Coverage rules for oxygen therapy and oxygen delivery equipment (stationary, portable, ambulatory, and concentrators) for Medicaid members, including adult and pediatric criteria, qualifying lab values, reassessment, and short-term use guidance.

Policy Summary

Payernorthwood

PolicyOxygen and Oxygen Equipment (Medicaid) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2020

Next Review DateDec 10, 2025

Key ActionProvide blood gas or pulse oximetry reports and documentation of practitioner exam at required intervals to support ongoing oxygen therapy.

SourceLink

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.

CurrentnorthwoodPolicy N/A

Oxygen and Oxygen Equipment (Medicaid) - Coverage Criteria

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Policy Summary

Payernorthwood

PolicyOxygen and Oxygen Equipment (Medicaid) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2020

Next Review DateDec 10, 2025

Key ActionProvide blood gas or pulse oximetry reports and documentation of practitioner exam at required intervals to support ongoing oxygen therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≤55/≤88PaO2/SpO2 threshold (continuous)

56–59 / 89Conditional PaO2/SpO2 range

12/3/1 moReassessment timing

10 lbsAmbulatory weight cut-off

36 moReference rental period

E0467Bundled code

Coverage Criteria for Oxygen Therapy and Equipment

Continuous (continuous/home) oxygen

Covered when ALL of the following are met for continuous oxygen therapy:

Adult continuous oxygen criteria: Member has a diagnosis of severe lung disease or other hypoxia-related condition listed in policy (e.g., COPD, cystic fibrosis, bronchiectasis, diffuse interstitial lung disease, widespread pulmonary neoplasm, or erythrocytosis/recurring cor pulmonale/pulmonary hypertension) AND one of the following resting oxygenation results: PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%, OR PaO2 56–59 mm Hg or SpO2 89% accompanied by at least one of: dependent edema suggesting CHF, erythrocythemia (Hct >56%), or P pulmonale on ECGSee text

Qualifying studies must be done on room air unless medically contraindicated.

Non-continuous (exercise or sleep) oxygen

Covered when ALL of the following are met for non-continuous oxygen:

Non-continuous oxygen indications: Hypoxemia demonstrated by testing for the indicated activity AND oxygen flow rate and number of hours/day are specified in the prescription. Indications include: (a) During exercise: PaO2 ≤ 55 mm Hg or SpO2 ≤ 88% with low-level exertion; (b) During sleep: PaO2 ≤ 55 mm Hg or SpO2 ≤ 88% with associated complications such as pulmonary hypertension, daytime somnolence, or cardiac arrhythmias.See text

Flow rate and hours/day must be specified on the prescription.

Oxygen delivery system coverage

Device coverage tied to member activity level:

Stationary systems: Stationary concentrators, liquid reservoirs, or large cylinders for members who do not regularly go beyond the limits of a stationary system with 50-ft tubing or who use oxygen only during sleep.N/A

Portable systems (weighing ≥ 10 lbs) for members who occasionally go beyond stationary limits for less than 2 hours/day for most days of the week (minimum 2 hours/week).weight ≥10 lbs; <2 hours/day typical

Designed to be transported but not easily carried; e.g., wheeled cylinders.

Ambulatory systems (weighing < 10 lbs when filled) that will last ~4 hours at 2 L/min continuous flow for members who regularly go beyond stationary limits ≥2 hours/day for most days of the week (minimum 6 hours/week).weight <10 lbs; 4 hours at 2 L/min; ≥2 hours/day use

Prescription based on activity status of the member.

Pediatric coverage

Pediatric criteria — Covered when ALL of the following are met:

Pediatric oxygen criteria: Member is <21 years of age AND laboratory testing demonstrates hypoxemia (PaO2 ≤ 65 mm Hg or SpO2 ≤ 90%) AND oxygen is required during relevant activities (sleeping, feeding, resting). Eligible pediatric diagnoses include BPD, cystic fibrosis, pulmonary fibrosis, pulmonary insufficiency of prematurity (PIP), tracheomalacia, agenesis/hypoplasia/dysplasia of the lung, chronic cardiopulmonary disease (cor pulmonale), P pulmonale on EKG, erythrocytosis, or other diagnoses based on medical necessity.SpO2 ≤90% or PaO2 ≤65 mm Hg

For portable systems, ambulation outside the home must be necessary.

Reassessment and short-term therapy

Short-term and reassessment rules:

Short-term therapy: Certain diagnoses (e.g., asthma, bronchitis, croup, pneumonia) may be reasonable and necessary for short-term oxygen generally less than 1 month; requests for use beyond short-term are reviewed individually. For ongoing treatment related to these diagnoses, repeat qualifying lab values are reviewed monthly.<1 month typical

Reassessment timing: Independent respiratory provider reassessment by pulse oximetry or arterial blood gas is required 12 months after initiation for those qualifying with PaO2 ≤55 mm Hg or SpO2 ≤88%, or at 3 months after initiation for those qualifying with PaO2 56–59 mm Hg or SpO2 89% with dependent edema, P pulmonale, or erythrocythemia.12 months or 3 months as specified

Repeat testing more frequently for short-term diagnoses per policy.

Medical necessity and testing requirements

Covered when documentation meets the testing and prescription requirements and hypoxemia is demonstrated

Initial and follow-up testing: Hypoxemia must be demonstrated by recent arterial blood gas analysis or pulse oximetry performed by the treating practitioner or an independent respiratory practitioner. Testing is required at 1 month after initiation for expected short-term conditions and at 3 months after initiation for other conditions; thereafter report results within 12 months of initiation and whenever oxygen amount or equipment type changes.See node

Blood gas values should be obtained on room air unless medically contraindicated.

Prescription and practitioner exam: Home oxygen must be prescribed by a practitioner who has seen and examined the patient within one month of the request; the prescription must specify diagnosis, oxygen flow rate, and estimated frequency and duration of therapy.

A new order is required and must be kept on file when flow-rate categories or equipment types change.

Repeat blood gas required scenarios: Repeat blood gas is required when the prescribed maximum flow rate changes across categories (<1 LPM; 1–4 LPM; >4 LPM), or when changing from one type of stationary system to another, or when changing from one type of portable system to another.

Medical necessity and documentation conditions

Covered when documentation and medical necessity are established and the member's contract permits coverage

Basic coverage conditions: Treating practitioner documents a medical condition for which DME is prescribed; a face-to-face examination was conducted within six months prior to the written order (ACA 6407); required documentation is received by the provider prior to delivery for certain DME items; and the equipment is used primarily for a medical purpose and meets medical necessity criteria.

Final benefit determinations are based on the member's contract; policy guidelines do not override contract language.

Pediatric medical necessity updates

Policy records updates to medical necessity and pediatric criteria

Pediatric criteria updates: Policy updates include the addition of medical necessity diagnoses for pediatric members and specification of acceptable lab/oximetry results for pediatrics as reflected in recent annual updates.

Per 2020–2021 updates and subsequent annual reviews.

Ventilation and monthly payment

Policy notes billing and payment interactions

Ventilation system billing: Noninvasive OPEN ventilation system (E1352) is classified as an accessory to oxygen equipment and is included in the monthly bundled payment for oxygen. Certain historical codes (e.g., K0741, K0742) were deleted per policy history.

All options, supplies and accessories may be considered included in the monthly rental payment.

Home oxygen therapy is not reasonable and necessary for indications other than those expressly listed in this policy. Examples of non-covered clinical scenarios include: angina pectoris without hypoxemia, dyspnea without cor pulmonale or documented hypoxemia, severe peripheral vascular disease with localized desaturation but no systemic hypoxemia, terminal illnesses that do not affect the respiratory system, sleep apnea that does not otherwise qualify, headaches other than cluster headaches, treatment of pediatric seizures, and prophylactic home oxygen in pregnancy to reduce transfusion-related adverse events in sickle cell disease.

Emergency or stand-by oxygen systems intended for members who are not regular oxygen users are considered precautionary rather than therapeutic and therefore are not reasonable and necessary. Topical oxygen therapies, including topical hyperbaric oxygen chambers (A4575) and topical oxygen delivery systems (E0446), are specifically denied as not reasonable and necessary. Per CMS-related updates, topical oxygen therapy guidance and codes were added to the policy during annual updates.

Durable Medical Equipment (DME) for oxygen is limited to devices and supplies that are used primarily for a medical purpose. Equipment that is used primarily and customarily for a non-medical purpose does not meet the definition of DME and is excluded from coverage under this policy.

The policy change history documents that HCPCS codes K0741 and K0742 were deleted from the policy and are no longer included as covered codes.

A determination that oxygen therapy is medically reasonable and necessary under the criteria in this policy does not by itself guarantee coverage. Final coverage is subject to the terms, conditions, limitations, and exclusions of the member's contract; items excluded by the contract remain non-covered even if clinical criteria are met.

Topical oxygen therapy (TOT) for wound healing is considered not reasonable and necessary based on the available evidence. Topical hyperbaric oxygen chambers and topical delivery systems will be denied.

Coverage determinations and any conclusion of medical necessity are contingent on the member's benefit contract. If the member's contract explicitly excludes an item or service, that exclusion takes precedence and the item will not be covered despite meeting clinical criteria in this policy.

The policy’s change log (2019) added examples to the experimental and investigational list, including pediatric seizures and prophylactic oxygen use to reduce transfusion-related adverse events in pregnant women with sickle cell disease; such uses are considered experimental/investigational and are not covered.

HCPCS, CPT, and Diagnostic Coding

Example diagnosis code mentionedHCPCS

E0431

Cluster headaches (listed example)

EquipmentHCPCS

E0424	STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM, RENTAL
E0425	STATIONARY COMPRESSED GAS SYSTEM, PURCHASE
E0430	PORTABLE GASEOUS OXYGEN SYSTEM, PURCHASE
E0431	PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL
E0433	PORTABLE LIQUID OXYGEN SYSTEM, RENTAL
E0434	PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING
E0435	PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE
E0439	STATIONARY LIQUID OXYGEN SYSTEM, RENTAL
E0440	STATIONARY LIQUID OXYGEN SYSTEM, PURCHASE
E0441	STATIONARY OXYGEN CONTENTS, GASEOUS, 1 MONTH'S SUPPLY = 1 UNIT

1–10 of 22

1/3

AccessoriesHCPCS

A4575	TOPICAL HYPERBARIC OXYGEN CHAMBER, DISPOSABLE
A4608	TRANSTRACHEAL OXYGEN CATHETER, EACH
A4615	CANNULA, NASAL
A4616	TUBING (OXYGEN), PER FOOT
A4617	MOUTHPIECE
A4619	FACE TENT
A4620	VARIABLE CONCENTRATION MASK
A7525	TRACHEOSTOMY MASK, EACH
E0455	OXYGEN TENT, EXCLUDING CROUP OR PEDIATRIC TENTS
E0555	HUMIDIFIER, DURABLE, FOR USE WITH REGULATOR OR FLOWMETER

1–10 of 18

1/2

Bundled/Combined equipmentHCPCS

E0467

VENTILATOR THAT INTEGRATES MULTIPLE FUNCTIONS, BUNDLES OXYGEN EQUIPMENT AND OTHER DEVICES

Historical HCPCS codes mentioned in change historyHCPCS

E1354	HCPCS code added (blood gas studies) as listed in change history
E1356	HCPCS code added (blood gas studies) as listed in change history
E1357	HCPCS code added (blood gas studies) as listed in change history
E1358	HCPCS code added (blood gas studies) as listed in change history
E0433	Portable oxygen concentrator (added per change history)
E0441	Referenced in narrative changes (was changed per history)
E0442	Stationary oxygen contents, liquid, 1 month's supply
E0444	Portable oxygen contents, liquid, 1 month's supply

HCPCS codes referencedHCPCS

E0442	Stationary oxygen contents, liquid, 1 month's supply = 1 unit
E0444	Portable oxygen contents, liquid, 1 month's supply = 1 unit
E1352	Noninvasive OPEN ventilation system (included in monthly payment for oxygen)
E0446	Topical oxygen therapy (code added per CMS)
A4575	Topical oxygen therapy (code added per CMS)
E0447	HCPCS added per CMS (document notes addition)
E0467	HCPCS added per CMS (document notes addition)
K0741	Deleted from policy
K0742	Deleted from policy

Oxygenation thresholds — Resting and conditional thresholds (adult and pediatric)

Adult — resting hypoxemia thresholdResting PaO2 ≤ 55 mm Hg or SpO2 ≤ 88%

Adult — conditional thresholdResting PaO2 56–59 mm Hg or SpO2 89% when accompanied by dependent edema suggesting CHF, erythrocythemia (Hct >56%), or P pulmonale on ECG

Adult — higher values require justificationResting PaO2 >59 mm Hg or SpO2 >89% only with additional documentation justifying oxygen prescription and summary of failed conservative therapy

Pediatric — thresholdFor members <21 years: PaO2 ≤ 65 mm Hg or SpO2 ≤ 90% (oxygen required during activities such as sleeping, feeding, resting)

Provider Actions, Prior Authorization, and Billing Guidance

Prior Authorization

Prior review required for portable/ambulatory systems

Prior authorization/review is required when prescribing portable oxygen concentrators, ambulatory systems, or portable wheeled systems that serve as medically necessary alternatives to ambulatory oxygen — suppliers and clinicians should obtain prior review for these portable/ambulatory systems when the member meets ambulatory criteria and is regularly away from home beyond ambulatory capacity.

Portable oxygen concentrators are considered an alternative to ambulatory systems when member meets ambulatory criteria and is regularly (at least monthly) away from home for durations that exceed ambulatory capacity.
Ambulatory vs portable selection depends on weight, duration, and activity thresholds (ambulatory <10 lbs; portable ≥10 lbs).

Step Therapy

Testing and reordering timing for new orders

Obtain and document qualifying blood gas or pulse oximetry results at the required intervals: 1 month after initiation for expected short-term conditions and 3 months after initiation for other conditions; thereafter report pulse oximetry or arterial blood gas within 12 months of initiation and whenever oxygen amount or equipment type changes.

Medical Necessity Requirements

Equipment selection criteria

Equipment selection is based on the member's activity level and oxygenation needs:

Stationary equipment need: Member does not regularly go beyond the limits of a stationary system with 50-ft tubing or uses oxygen only during sleep.N/A

Portable equipment need: Member occasionally goes beyond stationary limits for less than 2 hours/day for most days (minimum 2 hours/week); equipment typically weighs ≥10 lbs and is transportable but not easily carried.<2 hours/day typical; weight ≥10 lbs

Ambulatory equipment need: Member regularly goes beyond stationary limits ≥2 hours/day for most days (minimum 6 hours/week); ambulatory equipment weighs <10 lbs when filled and will last about 4 hours at 2 L/min continuous flow.

Rental, Purchase, and Monthly Payment Rules

Equipment	Rental/Purchase classification
Portable oxygen concentrators, ambulatory systems, portable wheeled systems	neutral — treated as alternatives to ambulatory systems when ambulatory criteria met; classification depends on specific HCPCS code and clinical need (see individual HCPCS entries).
Ambulatory systems (<10 lbs, carryable; lasts ~4 hours at 2 L/min)	Purchase or rental as identified by HCPCS; ambulatory systems described as equipment for members who regularly go beyond stationary limits ≥2 hours/day (prescription based on activity).

HCPCS / Item examples	Rental or Purchase (per HCPCS) / Notes
E0424 — STATIONARY COMPRESSED GASEOUS OXYGEN SYSTEM	Rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0425 — STATIONARY COMPRESSED GAS SYSTEM	Purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0430 — PORTABLE GASEOUS OXYGEN SYSTEM	Purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing.
E0431 — PORTABLE GASEOUS OXYGEN SYSTEM	Rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing.
E0433 / E0434 — PORTABLE LIQUID OXYGEN SYSTEMS	Rental; home liquefier used to fill portable containers (E0433) and includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing.
E0435 — PORTABLE LIQUID OXYGEN SYSTEM	Purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor.
E0439 — STATIONARY LIQUID OXYGEN SYSTEM	Rental.
E0467 — Bundled ventilator/oxygen functionality (lists multiple included HCPCS)	Considered bundled — HCPCS codes listed as included in E0467 (e.g., E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E0447, E1390, E1391, E1392, E1405, E1406, K0738). Claims for included codes submitted with overlapping dates are considered unbundling.

Equipment / HCPCS examples	Rental/Purchase classification / Notes
E0433 — PORTABLE LIQUID OXYGEN SYSTEM, RENTAL	Rental; home liquefier used to fill portable liquid oxygen containers; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing, with or without supply reservoir and contents gauge.
E0434 — PORTABLE LIQUID OXYGEN SYSTEM, RENTAL	Rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing.
E0435 — PORTABLE LIQUID OXYGEN SYSTEM, PURCHASE	Purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor.

Item / HCPCS	Coverage or payment note (monthly payment)
E1352 — NONINVASIVE OPEN VENTILATION SYSTEM (NIOV)	Included in the monthly payment for oxygen (bundled into oxygen monthly payment).

Replacement, Maintenance, and Useful Lifetime

inv-58: Equipment listed as included in E0467 and other oxygen equipment — 36 months referenced as rental milestone

E0467 bundled items milestoneClaims for HCPCS codes included in E0467 that overlap with E0467 are considered unbundling; rental-month/ownership situations may be considered same or similar equipment

36-month rental milestoneEquipment that has reached the 36-month rental milestone but not end of reasonable useful lifetime is considered in same-or-similar determinations

Included equipment examplesE0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E0447, E1390, E1391, E1392, E1405, E1406, K0738 are listed as included in E0467

inv-59: Maintenance and servicing months — referenced Medicare policy changes for months 37-60 (historical)

Maintenance/servicing months referencePolicy updated to reflect Medicare guidance on maintenance and servicing months 37–60 (historical reference)

Documentation Requirements and Intervals

Documentation Required

Submit required blood gas or pulse oximetry reports and prior conservative therapy documentation

Provide blood gas or pulse oximetry reports performed by the treating practitioner or an independent respiratory practitioner at the required intervals; include documentation of prior conservative therapies when applicable.

Testing must be done on room air unless medically contraindicated.
Include documentation of prior conservative therapy attempts when oxygen is prescribed at higher thresholds.

Billing Rule

Maintain new orders on supplier file and document repeat testing for changes

Keep the new order on the supplier's file when indicated and document repeat testing whenever the prescribed flow rate category or equipment type changes.

Not Covered / Exclusions

Oxygen therapy and related equipment are not covered when provided for indications not listed in the policy or when exclusion conditions apply (examples above). This includes topical oxygen therapies (A4575, E0446) and emergency/stand-by systems for non-regular users, items primarily for non-medical purposes, and uses designated as experimental or investigational in the policy history (see 2019 additions). Final coverage decisions remain subject to member contract language.

Topical oxygen therapies and topical hyperbaric chambers (A4575, E0446) are denied as not reasonable and necessary. Emergency or stand-by oxygen systems for members who are not regularly using oxygen are likewise considered not reasonable and necessary because they are precautionary rather than therapeutic.

Items or equipment that are used primarily and customarily for a non‑medical purpose do not meet the definition of DME and are excluded from coverage. Additionally, items excluded by the member's contract are not covered even if clinically reasonable under this policy.

This exclusion reiterates that oxygen therapy for home use is considered not reasonable and necessary for indications outside those explicitly listed in the policy (for example, angina without hypoxemia, dyspnea without cor pulmonale or hypoxemia, and other conditions listed in the exclusions section).

Background and Clinical Context

Oxygen therapy is used to treat hypoxemia associated with a range of pulmonary and cardiopulmonary conditions. Indications covered include chronic lung diseases (such as COPD, cystic fibrosis, pulmonary fibrosis), hypoxia-related complications (erythrocytosis, pulmonary hypertension), and select short-term illnesses (for example, pneumonia, asthma, bronchitis) where oxygen may be reasonable for <1 month. Pediatric criteria differ and include higher SpO2/PaO2 thresholds and specific pediatric diagnoses; the pediatric population is defined as members <21 years of age.

Key Definitions

inv-46: Pediatric member defined as under 21 years of age

Pediatric age definitionPediatric member = under 21 years of age for pediatric oxygen therapy criteria

Pediatric qualifying labsFor members <21: PaO2 ≤65 mm Hg OR SpO2 ≤90% required to meet pediatric oxygen criteria

Pediatric activity requirementFor portable systems, above criteria must be met AND ambulation outside the home must be necessary

inv-47: TOT — Topical oxygen therapy definition

TOT definitionTopical oxygen therapy (TOT) — delivery of oxygen to a wound surface via intermittent enclosed low-pressure chamber or continuous low-flow diffusion (CDO)

Intermittent TOTLow pressure (0.049–1.03 atm) delivered in closed chamber sessions (e.g., ~90 minutes/day for multiple consecutive days)

Revision History and Change Log

2009-01-03codes_added

HCPCS codes E1354, E1356, E1357, and E1358 were added (blood gas studies) and testing/certification language updated in the January 2009 revision.

2010-01-05codes_added

Code E0433 (portable liquid oxygen system) was added in the January 2010 update.

2019-12-18codes_added_and_policy_change

Policy Summary

Payernorthwood

PolicyOxygen and Oxygen Equipment (Medicaid) - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 1, 2020

Next Review DateDec 10, 2025

Key ActionProvide blood gas or pulse oximetry reports and documentation of practitioner exam at required intervals to support ongoing oxygen therapy.

SourceLink

On This Page

Portable oxygen concentrators (POCs) and combination stationary/portable systems may be used as an alternative to ambulatory systems when the member meets ambulatory criteria AND is regularly (at least monthly) away from home for durations that exceed ambulatory system capacity.regularly at least monthly away from home beyond ambulatory capacity

Prior review may be required for POCs/ambulatory systems.

Flow rate categories

Flow rate category 1Less than 1 LPM

Flow rate category 21–4 LPM

Flow rate category 3Greater than 4 LPM

Oxygen contents supply unit 1 month's supply = 1 unit

Standard definitionOne month’s supply = 1 unit (applies to oxygen contents supply measurements)

Monthly supply unit (duplicate reference)

Monthly supply unit (general)1 month’s supply = 1 unit (used for gaseous and liquid oxygen contents HCPCS)

Gaseous contents exampleE0441: Stationary oxygen contents, gaseous, 1 month’s supply = 1 unit

Liquid contents exampleE0442/E0444: Stationary and portable liquid oxygen contents, 1 month’s supply = 1 unit

Short-term conditions (e.g., pneumonia, asthma, bronchitis, bronchiolitis): testing at 1 month.
Other conditions: testing at 3 months, then within 12 months and whenever oxygen or equipment changes.

Prior Authorization

Face-to-face exam and supporting documentation required prior to delivery

Treating practitioner must have conducted a face-to-face examination within six months prior to the written order and supporting documentation describing the medical condition must be received prior to delivery for certain DME items.

ACA 6407 requires face-to-face exam during the six-month period preceding the written order and documentation must be received prior to delivery for certain DME.
CMN submission is no longer required for services after 1-1-23, but required documentation must still be received when noted.

Documentation Required

Adhere to CMS HCPCS additions and CMN update

Follow CMS additions and related documentation guidance: the policy includes HCPCS additions A4575, E0446, E0447 and E0467; ensure claims and supporting documentation reflect these codes and CMS CMN updates effective 1-1-23.

A4575 and E0446 were added per CMS and addressed in policy revisions.
HCPCS E0447 and E0467 were added (see change history); CMN updates effective 1-1-23 should be followed when submitting claims.

Documentation Required

Document trials/failure of conservative therapy if PaO2>59 or SpO2>89%

When resting PaO2 is greater than 59 mm Hg or SpO2 is greater than 89%, document trials or failure of more conservative therapies and provide a summary justifying the oxygen prescription.

Resting PaO2 >59 mm Hg or SpO2 >89% requires additional documentation justifying oxygen and a summary of conservative therapy that has failed.
Document conservative treatment trials before initiating home oxygen when thresholds are above standard criteria.

Step Therapy

Attempt alternatives and demonstrate hypoxemia before initiating oxygen

Consider and attempt alternative treatments before initiating home oxygen; hypoxemia must be demonstrated by recent blood gas analysis or pulse oximetry prior to prescribing oxygen.

Alternative treatment methods should be considered and attempted prior to initiating home oxygen therapy.
Hypoxemia must be demonstrated by recent blood gas analysis or pulse oximetry (on room air unless contraindicated).

Note

(No action)

(No specific provider action text provided in source.)

Note

(No action)

(No specific provider action text provided in source.)

Documentation Required

Document qualifying lab values on room air unless contraindicated

Document qualifying lab values with blood gas analysis or pulse oximetry obtained on room air unless medically contraindicated; documentation may come from physician office, hospital, or outpatient laboratory.

All qualification studies must be done on room air unless medically contraindicated.
Blood gas values or pulse oximetry results can be documented from office, hospital, or outpatient lab sources.

Documentation Required

Provide proof of continued need and complete prescription details

Provide proof of continued need via blood gas results or pulse oximetry performed by the treating practitioner or an independent respiratory practitioner at the required intervals; the prescription must state diagnosis, oxygen flow rate, and estimated frequency and duration, and the practitioner must have seen and examined the patient within one month of the request.

Proof of continued need testing schedule: 1 month for expected short-term conditions, 3 months for other conditions, then within 12 months of initiation and whenever oxygen amount or equipment changes.
Prescription must specify diagnosis, flow rate, frequency and duration; treating practitioner must have examined patient within one month of request.

Documentation Required

Ensure face‑to‑face exam within six months before order

Treating practitioner must conduct a face-to-face examination within six months prior to the written order (ACA 6407) and documentation describing the medical condition must be received by the supplier prior to delivery for certain DME items.

Face-to-face exam required during the six-month period preceding the written order per ACA 6407.
Supplier must receive documentation describing the medical condition prior to delivery when required.

Documentation Required

Follow CMN update effective 1-1-23 (CMS guidance)

Per CMS, providers and suppliers should follow the CMN updates effective 1-1-23, which include references to medical necessity diagnoses for pediatric members and acceptable lab/oximetry results for pediatrics.

CMN submission not required for services after 1-1-23, but follow CMS guidance and updated documentation expectations.
Policy updates include pediatric diagnoses and acceptable lab/oximetry thresholds in line with CMS updates.

Denial Risk

Avoid prescribing oxygen for unlisted indications (risk of denial)

Do not request home oxygen for indications not listed in the policy (e.g., angina without hypoxemia, dyspnea without cor pulmonale or hypoxemia); such requests will be considered not reasonable and necessary and may be denied.

Examples of not reasonable and necessary indications include angina pectoris without hypoxemia, dyspnea without cor pulmonale or hypoxemia, and headaches other than cluster headaches.
Final coverage decisions are subject to the member's contract terms, conditions, limitations, and exclusions.

Denial Risk

Topical oxygen therapies (A4575, E0446) — will be denied

Topical hyperbaric oxygen chambers (A4575) and topical oxygen delivery systems (E0446) are not reasonable and necessary and will be denied.

A4575 (topical hyperbaric oxygen chamber) and E0446 (topical oxygen delivery system) are denied as not reasonable and necessary.
Per CMS updates, topical oxygen therapy information and codes were added to policy revisions.

Billing Rule

Do not unbundle codes included in E0467

Claims for HCPCS codes that are included in E0467 submitted on the same claim or with overlapping dates of service with E0467 are considered unbundling and may be denied; repair claims and overlapping rental/ownership scenarios described for E0467 also apply.

HCPCS codes included in E0467 (e.g., E0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444, E0447, E1390, E1391, E1392, E1405, E1406, K0738) must not be billed separately on the same claim or overlapping dates with E0467.
Overlapping repair claims or scenarios where the beneficiary is in a rental month, owns equipment not at end of useful life, or reached 36-month rental but not end of useful life are considered unbundling.

Denial Risk

Coverage subject to member contract terms and exclusions

Coverage determinations remain subject to the member's contract — final benefit decisions consider terms, conditions, limitations, exclusions, and state requirements; equipment primarily for non‑medical purposes is not DME and may be denied.

Even if clinically reasonable, coverage is defined by the member's contract and may exclude items.
Policy criteria supplement but do not override contract language or applicable state requirements.

Note

Ensure compliance with ACA 6407 where applicable

Items in this policy may be subject to Affordable Care Act (ACA) 6407 requirements; ensure documentation and face-to-face exam compliance per ACA when applicable.

ACA 6407 requires a treating practitioner face-to-face exam within six months preceding the written order for certain DME.
Policy change history notes addition of ACA 6407 applicability.

≥2 hours/day; 4 hours at 2 L/min; weight <10 lbs

Prescription should reflect activity status.

Portable concentrator need: Member meets ambulatory criteria AND is regularly (at least monthly) away from home for durations that exceed ambulatory system capacity; portable oxygen concentrators may be considered as alternatives to ambulatory systems in this situation.at least monthly away from home beyond ambulatory capacity

Prior review may be required for portable concentrators.

DME medical necessity

Equipment is medically necessary when testing and prescription requirements are met:

Demonstration of hypoxemia: Recent arterial blood gas or pulse oximetry demonstrating hypoxemia performed by the treating practitioner or an independent respiratory practitioner; blood gas should be obtained on room air unless medically contraindicated.

Alternative treatments should be considered prior to initiating home oxygen.

Follow-up testing: Repeat testing at 1 month for expected short-term conditions or at 3 months for other conditions after initiation; thereafter report pulse oximetry or arterial blood gas within 12 months and whenever oxygen amount or equipment type changes.See text

New orders required and must be kept on file by supplier when indicated.

Prescription requirements: Practitioner must have seen and examined the patient within one month of the request; prescription must document diagnosis, oxygen flow rate, and estimated frequency and duration of therapy.

A new order and repeat blood gas may be required when flow or equipment categories change.

Oxygen DME medical necessity

Oxygen DME is medically necessary when documentation and evaluation support the need:

DME oxygen medical necessity: Treating practitioner documents a medical condition requiring oxygen; face-to-face examination conducted within six months prior to the written order (ACA 6407); required documentation received by the provider prior to delivery for certain DME items; device is used primarily for a medical purpose and meets medical necessity criteria.

Final coverage determinations depend on member contract language and exclusions.

General and pediatric medical necessity

References and pediatric testing guidance related to medical necessity:

General medical necessity: Coverage aligns with Medicare/CMS guidance and includes CMN/CMN-related updates; pediatric testing thresholds and acceptable oximetry/arterial blood gas results are specified in policy updates.

See CMS and annual policy updates for details.

Policy historyRevisions referenced changes to Medicare policy and LCD dated 7-1-10 covering months 37–60

ImplicationHistorical policy language guided payment and service expectations during months 37–60 of rental/maintenance period

inv-60: Liquid oxygen monthly supply units — 1 month's supply = 1 unit

Liquid oxygen monthly supply unitOne month's supply (liquid) = 1 unit (applies to stationary and portable liquid contents)

HCPCS examplesE0442 (stationary liquid) and E0444/E0447 (portable liquid variants) referenced in policy revisions

Billing useMonthly supply unit used to bill for liquid oxygen contents as monthly units

Supplier must retain current orders; obtain repeat blood gas when flow-rate category changes or when switching equipment types.
Prescription must specify diagnosis, flow rate, frequency and duration.

Documentation Required

Face-to-face exam and supporting documentation must be provided before delivery

Treating practitioner must conduct a face-to-face examination within six months prior to the written order and documentation describing the medical condition must be received by the provider prior to delivery for certain DME items.

ACA 6407 face-to-face exam requirement applies; documentation must describe the medical condition for which DME is prescribed.

Documentation Required

Follow updated CMN/CMS documentation guidance (effective 1-1-23)

Adhere to the updated Certificate of Medical Necessity (CMN) guidance per CMS effective 1-1-23; while CMN submission is no longer required for services after that date, follow CMS documentation and coding guidance when submitting claims.

Per CMS, CMN providers and suppliers no longer need to submit CMN for services after 1-1-23, but follow the CMS updates and documentation expectations.
Ensure pediatric diagnosis and lab/oximetry documentation align with the updated policy language.

Continuous TOT (CDO)Low-flow oxygen (<1 L/min) applied continuously to wound surface through a cannula in a dressing

inv-48: Durable Medical Equipment (DME) definition

DME definition (general)Durable medical equipment (DME) is equipment used primarily for a medical purpose; items used primarily for non-medical purposes are not considered DME

Coverage dependencyFinal coverage determinations depend on the member's contract terms, conditions, limitations, and exclusions

Policy purposeMedical policy provides criteria to determine medical necessity but does not itself confer coverage when contract excludes an item

inv-49: Monthly supply unit definitions for liquid oxygen HCPCS

Stationary liquid contents (monthly unit)E0442 — Stationary oxygen contents, liquid; 1 month's supply = 1 unit

Portable liquid contents (monthly unit)E0444/E0447 — Portable oxygen contents, liquid; 1 month's supply = 1 unit (E0447 noted when prescribed amount at rest/nighttime exceeds 4 LPM)

Gaseous contents (monthly unit)E0441/E0443 — Stationary/portable gaseous oxygen contents defined historically as 1 month's supply = 1 unit

Per CMS, HCPCS codes E0447 and E0467 were added and certain items were listed as experimental/investigational (including pediatric seizures and prophylactic use in pregnancy for sickle cell disease).

2020-01-06pediatric_definition_update

Policy updated to reflect the American Academy of Pediatrics definition for pediatric age and related pediatric testing/diagnosis language was added.

2020-12-11codes_and_tot_update

Per CMS guidance, Topical Oxygen Therapy information and codes A4575 and E0446 were added to the policy during the December 2020 annual review.

2014-11-25annual_review_and_ACA_note

Annual review updated and policy noted that items may be subject to Affordable Care Act (ACA) 6407 requirements; Noninvasive OPEN ventilation system (E1352) referenced as included in monthly oxygen payment.

2019-12-18codes_and_payment_update

CMS additions included HCPCS E0447 and E0467; policy deleted codes K0741 and K0742 and referenced E1352 as included in the monthly payment for oxygen.

2022-12-15cmn_update

Annual review noted Per CMS CMN update effective 2023-01-01 (Certificate of Medical Necessity changes) and related documentation updates.

2023-12-15annual_review_no_change

Annual review completed with no clinical changes recorded.

2024-12-12annual_review_no_change

Annual review completed with no clinical changes recorded.

2025-12-10annual_review_scheduledLatest

Next annual review scheduled (document lists December 10, 2025) and prior entry shows annual review dated December 10, 2025 in policy timeline.