CurrentRegencePolicy 91

Oxygen Concentrators

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This policy governs when oxygen concentrators may be considered medically necessary for members whose contracts are subject to oxygen preauthorization requirements. Coverage applies to providers prescribing or dispensing oxygen concentrators and is subject to applicable contract terms.

Policy Summary

PayerRegence

PolicyOxygen Concentrators

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDecember 1, 2025

Last ReviewOct 1, 2025

Next Review DateSeptember 1, 2026

Key ActionCheck the preauthorization website to confirm whether the member contract requires authorization for oxygen equipment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Medical necessity criteria

E1390/E1391Listed HCPCS codes

E0467Separate concentrator exclusion

85%+Oxygen concentration capability

1-5 L/minCommon flow range

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CurrentRegencePolicy 91

Oxygen Concentrators

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Policy Summary

PayerRegence

PolicyOxygen Concentrators

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDecember 1, 2025

Last ReviewOct 1, 2025

Next Review DateSeptember 1, 2026

Key ActionCheck the preauthorization website to confirm whether the member contract requires authorization for oxygen equipment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Medical necessity criteria

E1390/E1391Listed HCPCS codes

E0467Separate concentrator exclusion

85%+Oxygen concentration capability

1-5 L/minCommon flow range

Oxygen Concentrator Coverage Criteria

Initial oxygen concentrator therapy

Covered when ALL of the following criteria are met.

Initial oxygen concentrator coverage

Alternative treatment measures have been tried or considered.
Stable-state assessment: The patient has been tested in the chronic stable state and all coexisting diseases or conditions that can cause hypoxia have been treated sufficiently.
Severe lung disease or responsive hypoxia: The patient has severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, or widespread pulmonary neoplasm, or has hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy.
No acute deterioration: The patient is not experiencing an exacerbation of the underlying lung disease or another acute condition affecting oxygen saturation.
OSA-related testing: The patient does not have obstructive sleep apnea, or, if obstructive sleep apnea is treated with concurrent positive airway pressure therapy, the qualifying oxygen saturation test was performed following optimal treatment of the obstructive sleep apnea.
No excluded indications
- No angina without hypoxemia: Angina pectoris is not present in the absence of hypoxemia.
- No dyspnea without objective support: Dyspnea is not present without cor pulmonale or evidence of hypoxemia.
- No isolated extremity desaturation: Severe peripheral vascular disease is not causing clinically evident desaturation in one or more extremities in the absence of systemic hypoxemia.
- No unrelated terminal illness: A terminal illness that does not affect the respiratory system is not present.

Not medically necessary circumstances

Not medically necessary in the following circumstances.

Noncovered circumstances

Criterion I not met: The patient does not meet all initial oxygen concentrator coverage criteria.
Multi-function home ventilator present: The patient has a multi-function home ventilator (E0467) and a separate oxygen concentrator is requested.

Oxygen concentrator use is not medically necessary when requested for angina pectoris without hypoxemia, dyspnea without cor pulmonale or evidence of hypoxemia, severe peripheral vascular disease causing clinically evident desaturation in one or more extremities without systemic hypoxemia, or a terminal illness that does not affect the respiratory system.

A separate oxygen concentrator is considered not medically necessary when the patient has a multi-function home ventilator (E0467).

Use of an oxygen concentrator is considered not medically necessary when all Criterion I requirements are not met. This includes failure to establish the required clinical indication, chronic stable-state need, qualifying oxygenation findings, and other applicable criteria.

When a patient has a multi-function home ventilator (E0467), a request for a separate oxygen concentrator is considered not medically necessary. The ventilator circumstance applies regardless of whether the patient otherwise requires supplemental oxygen.

Coding and Equipment Specifications

Listed HCPCS Oxygen Concentrator CodesHCPCS

E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate.
E1391	Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each.

Referenced HCPCS CodeHCPCSNot Covered

E0467

Multi-function home ventilator; referenced in the policy as a circumstance in which a separate oxygen concentrator is not medically necessary.

Concentrator oxygen concentration capability

Required oxygen concentration85 percent or greater

Applicable codesE1390 (single delivery port) and E1391 (dual delivery port)

Measurement conditionAt the prescribed flow rate

Common concentrator flow range

Common flow range1 to 5 L/min

Equipment contextOxygen concentrators

Typical delivery capability

Provider Requirements and Denial Risks

Prior Authorization

Confirm Contract-Specific Preauthorization

This policy applies only to member contracts subject to preauthorization for oxygen under the applicable group plan. Check the preauthorization website for the member contract to confirm requirements before requesting an oxygen concentrator.

Documentation Required

Document Oxygenation Assessment

Document the oxygenation assessment supporting the request. The need for supplemental oxygen must be evaluated by direct or indirect measurement of arterial oxygenation, including the partial pressure of oxygen and oxygen saturation of hemoglobin in arterial blood.

Record the applicable direct or indirect oxygenation measurements in the clinical documentation.
Identify the measurement method and the resulting oxygenation findings.

Clinical Background

Supplemental oxygen is used for chronic hypoxemia associated with cardiac or pulmonary disease. The need for oxygen is assessed using direct or indirect measurement of arterial oxygen partial pressure and/or hemoglobin oxygen saturation. Oxygen may be delivered through a nasal cannula, face mask, or tracheostomy from a stationary or portable oxygen source or concentrator; concentrators commonly deliver 1 to 5 L/min.

Key Definitions

Chronic stable state

DefinitionA period in which the patient has been tested without an exacerbation of the underlying lung disease or another acute condition affecting oxygen saturation.

Underlying disease statusThe underlying lung disease is not experiencing an exacerbation.

Coexisting conditionsCoexisting diseases or conditions that can cause hypoxia have been treated sufficiently.

Chronic oxygen therapy

DefinitionSupplemental oxygen delivered chronically through a nasal cannula, face mask, or tracheostomy.

Delivery sourcesA stationary or portable oxygen tank or an oxygen concentrator.

Medical Necessity Determination

Oxygen concentrator medical necessity

An oxygen concentrator may be considered medically necessary when ALL six criteria are met.

Six-criterion medical necessity decision

Criterion A — Alternative treatment: Alternative treatment measures have been tried or considered.
Criterion B — Chronic stable state and treated causes of hypoxia: The patient has been tested in the chronic stable state, and all coexisting diseases or conditions that can cause hypoxia have been treated sufficiently.
Criterion C — Severe lung disease or responsive hypoxia: The patient has severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, or widespread pulmonary neoplasm, or has hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy.

Documentation Checklist

Documentation Required

Support medical necessity with all six criteria

Document all six requirements supporting oxygen concentrator medical necessity before prescribing or dispensing the equipment.

Alternative treatment measures were tried or considered.
Testing was performed in the chronic stable state and coexisting causes of hypoxia were treated sufficiently.
The patient has severe lung disease or hypoxia-related symptoms or findings expected to improve with oxygen therapy.
The patient is not experiencing an exacerbation or another acute condition affecting oxygen saturation.
For treated OSA, the qualifying oxygen saturation test followed optimal OSA treatment.
None of the excluded indications are present.

Prior Authorization

Verify prior authorization before dispensing

Before dispensing oxygen equipment, check the preauthorization website for the member contract to confirm whether the group plan requires prior authorization. The policy applies only to member contracts subject to preauthorization for oxygen.

Not Covered Services

The following circumstances are not covered as medically necessary: use of an oxygen concentrator when the policy's required criteria are not met; a separate oxygen concentrator for a patient with a multi-function home ventilator (E0467); oxygen for angina pectoris without hypoxemia; dyspnea without cor pulmonale or evidence of hypoxemia; severe peripheral vascular disease causing isolated extremity desaturation without systemic hypoxemia; and a terminal illness that does not affect the respiratory system.

Policy Summary

PayerRegence

PolicyOxygen Concentrators

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDecember 1, 2025

Last ReviewOct 1, 2025

Next Review DateSeptember 1, 2026

Key ActionCheck the preauthorization website to confirm whether the member contract requires authorization for oxygen equipment.

SourceLink

On This Page

Concentrators may provide up to FiO2 0.95

Documentation Required

Verify Stable-State Testing and Treated Comorbidities

Document that the patient was tested in the chronic stable state and that all coexisting diseases or conditions that can cause hypoxia have been treated sufficiently. The patient must not be experiencing an exacerbation of the underlying lung disease or another acute condition affecting oxygen saturation.

Confirm testing occurred during the chronic stable state.
Document treatment of coexisting hypoxia-producing diseases or conditions.
Document the absence of an underlying-lung-disease exacerbation or other acute condition affecting oxygen saturation.

Documentation Required

Document OSA and Positive Airway Pressure Testing

For a patient with obstructive sleep apnea (OSA) who is receiving concurrent positive airway pressure therapy, document that the qualifying oxygen saturation test was performed following optimal treatment of the OSA. OSA that is not addressed by this qualifying testing does not satisfy the criterion.

Document concurrent positive airway pressure therapy when applicable.
Document that the qualifying oxygen saturation test followed optimal OSA treatment.

Documentation Required

Document Alternatives and Clinical Indication

Document that alternative treatment measures have been tried or considered and identify the severe lung disease or hypoxia-related symptoms or findings expected to improve with oxygen therapy.

Document alternatives tried or considered.
Document a qualifying severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, or widespread pulmonary neoplasm.
Alternatively, document hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy.

Denial Risk

Failure to Meet Required Criteria

Oxygen concentrator use is considered not medically necessary when the policy criteria are not met. Ensure all required criteria are documented before submitting the request.

The required criteria include alternative-treatment consideration, stable-state testing with treated hypoxia-producing conditions, a qualifying clinical indication, no acute condition affecting oxygen saturation, appropriate OSA testing when applicable, and none of the excluded conditions.

Denial Risk

Separate Concentrator with E0467 Ventilator

If the patient has a multi-function home ventilator (E0467), a request for a separate oxygen concentrator is considered not medically necessary.

Review whether the patient has an E0467 multi-function home ventilator before requesting a separate concentrator.
A separate oxygen concentrator request in this circumstance is subject to denial as not medically necessary.

Denial Risk

Excluded Clinical Indications

The following indications do not establish medical necessity for an oxygen concentrator when they occur without the required hypoxemia or qualifying clinical context.

Angina pectoris in the absence of hypoxemia.
Dyspnea without cor pulmonale or evidence of hypoxemia.
Severe peripheral vascular disease causing clinically evident desaturation in one or more extremities without systemic hypoxemia.
Terminal illness that does not affect the respiratory system.

Nasal cannula, face mask, or tracheostomy.

Criterion D — No acute condition affecting oxygen saturation: The patient is not experiencing an exacerbation of the underlying lung disease or another acute condition affecting oxygen saturation.

Criterion E — Obstructive sleep apnea testing: The patient does not have obstructive sleep apnea, or, if obstructive sleep apnea is treated with concurrent positive airway pressure therapy, the qualifying oxygen saturation test was performed following optimal treatment of the obstructive sleep apnea.

Criterion F — No excluded indications: None of the following are present: angina pectoris in the absence of hypoxemia; dyspnea without cor pulmonale or evidence of hypoxemia; severe peripheral vascular disease causing clinically evident desaturation in one or more extremities without systemic hypoxemia; or a terminal illness that does not affect the respiratory system.