Library: Policy

317:30-5-211.11. Oxygen and oxygen equipment

Revised 8-1-14

(a) Medical necessity.  Oxygen and oxygen supplies are covered when medically necessary.  Medical necessity is determined from results of arterial blood gas analysis (ABG) or pulse oximetry (SaO2) tests. ABG data are not required for children, but may be used if otherwise available. The test results to document Medical Necessity must be within 30 days of the date of the qualified medical practitioner's Certificate of Medical Necessity. Prior authorization is required after the initial three months of billing whether qualifying tests were done at rest, during sleep, or during exercise. Appropriate documentation of ABG or SaO2 data from the member's chart should be attached to the prior authorization request(PAR).

• (1) The ABG or oximetry test used to determine medical necessity must be performed by a medical professional qualified to conduct such testing.  The test may not be performed or paid for by a DMEPOS supplier, or a related corporation.  A referring qualified medical practitioner may perform the test in his/her office as part of routine member care.

• (2) In addition to ABG data, the following three tests are acceptable for determining medical necessity for oxygen prescription:

  • (A) At rest and awake "spot oximetry."

  • (B) During sleep:

    • i. Overnight Sleep Oximetry done inpatient or at   home.

    • ii. Polysomnogram, which may be used only if medically necessary for concurrent evaluation of another condition while in a chronic stable state.

  • (C) During exercise with all three of the following  performed in the same testing session.

    • i. At rest, off oxygen showing a non-qualifying  result.

    • ii. During exercise, off oxygen showing a qualifying event.

    • iii. During exercise, on oxygen showing improvement over test (C) ii above.

• (3) Certification criteria:

  • (A) All qualifying testing must meet the following criteria:

  • (B)  Adults. Initial requests for oxygen must include ABG or resting oximetry results. At rest and on room air, the arterial blood saturation (SaO2) cannot exceed 89% or the pO2 cannot exceed 59mm Hg.

  • (C) Children. Members 20 years of age or less must meet the following requirements:

    • (i) birth through three years, SaO2 equal to or less than 94%;or(ii) ages four and above, SaO2 level equal to or less than 90%.(iii)Requests from the qualified medical practitioner for oxygen for children who do not meet these requirements should include documentation of the medical necessity based on the child's clinical condition.  These requests are considered on a case-by-case basis.

(b) Certificate of medical necessity.

• (1) The DMEPOS supplier must have a fully completed current CMN(CMS-484 or HCA-32 must be used for members 20 years of age and younger) on file to support the claims for oxygen or oxygen supplies, and to establish whether coverage criteria are met and to ensure that the oxygen services provided are consistent with the physician's prescription (refer to instructions from Palmetto Government Benefits Administration, the Oklahoma Medicare Carrier, for further requirements for completion of the CMN).

• (2) The CMN must be signed by the qualified medical practitioner prior to submitting the initial claim.  If a verbal order containing qualifying data is received by the DME provider, oxygen and supplies may be dispensed using the verbal order date as the billing date.  The CMN initial date, the verbal order date, and the date of delivery should be the same date. It is acceptable to have a cover letter containing the same information as the CMN, stating the qualified medical practitioner's orders.  The CMN signed by the qualified medical practitioner must be attached to the PAR.

• (3) The medical and prescription information on the CMN may be completed by a non-physician clinician, or an employee, for the qualified medical practitioner's review and signature.

• (4) When a Certificate of Medical Necessity for oxygen is recertified, a prior authorization request will be required.

• (5) Re-certification and related retesting will be required every 12 months.

• (6) CMN for oxygen services must be updated at least annually and at any time a change in prescription occurs during the year. All DMEPOS suppliers are responsible for maintaining the prescription(s) for oxygen services and CMN in each member's file. 

• (7) The OHCA or its designated agent will conduct ongoing   monitoring of prescriptions for oxygen services to ensure guidelines are followed. Payment adjustments will be made on claims not meeting these requirements.