(Effective: September 27, 2021)
(Implementation Date: January 3, 2023)
What is covered:
Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period
Who is covered:
Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met:
A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patient’s treating practitioner meeting either of the following:
a. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood.
i. PO2 measurements can be obtained via the ear or by pulse oximetry.
ii. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services.
b. A clinical test providing the measurement of arterial blood gas.
i. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need.
B. The clinical test must be performed at the time of need:
a. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patient’s condition.
i. For inpatient hospital patient’s, the time of need is within 2 days of discharge.
ii. For patient’s whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy.
C. Beneficiary’s diagnosis meets one of the following defined groups below:
a. Group I:
i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or;
ii. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or
iii. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%.
a. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process.
1. During these events, oxygen during sleep is the only type of unit that will be covered.
2. Portable oxygen would not be covered.
iv. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise,
1. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day.
2. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
b. Group II:
i. Patients demonstrating arterial PO2 between 56-59 mm Hg, or who’s arterial blood oxygen saturation is 89%, with any of the following condition:
1. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or,
2. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the 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 AVFL; or,
3. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%.
c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patient’s age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity.
The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting:
- Angina pectoris (chest pain) in the absence of hypoxemia; or,
- Breathlessness without cor pulmonale or evidence of hypoxemia; or,
- Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or,
- Terminal illnesses, unless it affects the patient’s ability to breathe.
The MAC may determine necessary coverage for in home oxygen therapy for patient’s that do not meet the criteria described above. Initial coverage for patient’s experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioner’s prescription. Oxygen therapy can be renewed by the MAC if deemed medically necessary.
The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system.
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