Your doctor or healthcare provider must start with an office visit to discuss your symptoms before ordering any testing. If your symptoms are indicative of a chronic lung condition or other disease that requires long term oxygen therapy, Medicare will likely cover oxygen when the test results meet the coverage criteria outlined below.
Oxygen is covered if you have significant hypoxemia in a chronic stable state when:
You have a severe lung disease or hypoxemia that might be expected to improve with oxygen therapy, and
Your blood gas levels or oxygen saturation levels indicate the need for oxygen therapy, and
Your oxygen study was performed by a physician, qualified lab, other qualified provider and
Alternative treatments have been tried or deemed clinically ineffective.
Categories/Groups of oxygen therapy are based on the test results to measure your oxygen. There are two types of tests that can be used for this purpose. An Arterial Blood Gas (ABG) test is an invasive procedure which provides detailed information and a direct measurement of oxygen in arterial blood (from an artery). ABG test results are reported in millimeters of mercury (mmHg). A saturation test (SAT) is a non-invasive procedure that indirectly measures oxygen saturation using a sensor typically placed on the ear or finger. SAT test results are reported in percentages (%).
Group I Criteria: mmHG = 55, or saturation = 88%
For these results you must return to your physician or healthcare provider between 9-12 months after the initial visit to discuss whether your oxygen therapy should continue for lifetime or for a shorter period if the need is expected to end. Typically, you will not have to be retested when you return to your physician or healthcare provider for the follow-up visit.
Group II Criteria: 56-59 mmHg, or 89% saturation
For these results, you must return for another office visit with your physician or healthcare provider to discuss your oxygen therapy and for these borderline results you will also have to be retested within 3 months of the first test to continue therapy for lifetime or until the need is expected to end
Group III Criteria: mmHg = 60 or saturation = 90% is considered to be not medically necessary.
Note on nocturnal oxygen therapy: If you only require the use of oxygen during the nighttime, your doctor should rule out obstructive sleep apnea as a cause for the hypoxemia symptoms you may be experiencing. If obstructive sleep apnea is a potential factor, Medicare will not cover oxygen therapy until you have officially had the sleep apnea diagnosed and treated. When obstructive sleep apnea is a factor, testing for oxygen needs can only begin after the apneas are controlled with appropriate positive airway therapy using a CPAP or Bi-PAP.
Oxygen will be paid as a rental for the first 36 months. After that time, if you still need the equipment, Medicare will no longer make rental payments on the equipment. However, if equipment is still necessary, your supplier will continue to provide the equipment to you for an additional 24 months. During this two year service period, Medicare will pay your supplier for refilling your oxygen cylinders and for a semi-annual maintenance fee.
After 60 months of service through Medicare you may choose to receive new equipment.
Depending on which product is ordered, your supplier may not be able deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.