Oxygen
Medicare covers rental of oxygen equipment, or if you own your own equipment, Medicare will help pay for oxygen contents and supplies for the delivery of oxygen under these conditions:
- Your doctor says you have a severe lung disease or you're not getting enough oxygen and your condition might improve with oxygen therapy.
- Your arterial blood gas level falls within a certain range.
- Other alternative measures have been tried and failed, or were not helpful for you.
Under the above conditions, Medicare helps pay for:
- Systems for furnishing oxygen
- Containers that store oxygen
- Tubing and related supplies for the delivery of oxygen
- Oxygen contents
More Detailed Clinical Information
A quick summary of what Medicare considers in determining whether you qualify for oxygen therapy (and in much more detail down this page). If your oxygen levels are below a certain level, basically an arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, then you qualify (called Group 1). Or, if you have an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent with certain other conditions, you qualify (called Group 2). For patients with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent, there is a presumption of noncoverage, meaning the need for oxygen is not indicated by the test results.
Home oxygen therapy is covered only if all of the following conditions are met:
- The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, AND
- The patient's blood gas study meets the criteria stated below AND
- The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services AND
- The qualifying blood gas study was obtained under the following conditions:
- If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than two days prior to the hospital discharge date, OR
- If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the patient is in a chronic stable state - e.g., not during a period of acute illness or an exacerbation of their underlying disease, AND
- Alternative treatment measures have been tried or considered and deemed clinically ineffective.
Group I criteria include any of the following:
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake) OR
- An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake OR
- A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) OR
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter.
Group II criteria include:
- the presence of an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep, or during exercise (as described under Group I criteria) AND
- any of the following:
- Dependent edema suggesting congestive heart failure, or
- Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
- Erythrocythemia with a hematocrit greater than 56 percent.
Initial coverage for patients meeting Group II criteria is limited to three months or the physician specified length of need, whichever is shorter.
Portable Oxygen Systems
A portable oxygen system is covered if the patient is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not medically necessary. If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the stationary system.
If oxygen is provided only for use during sleep, portable oxygen would not be covered. Portable oxygen is not covered when provided only as a backup to a stationary oxygen system.
Oxygen is paid as a monthly rental. After 36 months, you own whatever equipment is provided and Medicare pays for service. Oxygen contents and accessories are included in the allowance for rented oxygen systems.
Explanation of Terms
hypoxemia - less than normal level of oxygen in the blood
Group 1 - chronic oxygen patients with obvious respiratory challenges as evidenced by low oxygen saturation
Group 2 - borderline oxygen patients. Their blood saturation levels seem to be within the normal range, but there are additional extenuating issues that suggest a need for oxygen
arterial PO2 - measurement of blood saturation
55 mm Hg - millimeters of mercury measuring partial pressure of oxygen
pulmonary hypertension - high blood pressure in the vessels that feed through the lungs - right side of the heart has to work harder to oxygenate blood
dependent edema - fluid in the tissues, usually ankles, wrists and the arms
Erythrocythemia - more hematocrit (red blood cells) than normal, very difficult to oxygenate those cells
