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National Coverage Determination (NCD)

Home Use of Oxygen

240.2

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Tracking Information

Publication Number
100-3
Manual Section Number
240.2
Manual Section Title
Home Use of Oxygen
Version Number
2
Effective Date of this Version
09/27/2021
Ending Effective Date of this Version
Implementation Date
01/03/2023
Implementation QR Modifier Date

Description Information

Benefit Category
Durable Medical Equipment


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

A. General

When used in the home, oxygen and oxygen equipment can make meaningful contributions to the treatment of patients with both acute and chronic conditions who require the medical gas on either a short- or long-term basis.
Indications and Limitations of Coverage

B. Nationally Covered Indications

Oxygen therapy and oxygen equipment is covered in the home for acute or chronic conditions, short- or long- term, when the patient exhibits hypoxemia as defined below.

Initial claims for oxygen therapy for hypoxemic patients must be based on the results of a clinical test that has been ordered and evaluated by the treating practitioner. Such a test is usually in the form of a measurement of the partial pressure of oxygen (PO2) in arterial blood. A measurement of arterial oxygen saturation obtained by ear or pulse oximetry, however, is also acceptable when ordered and evaluated by the treating practitioner and performed under his or her supervision or when performed by a qualified provider or supplier of laboratory services. A durable medical equipment (DME) supplier is not considered a qualified provider or supplier of laboratory services for purposes of this National Coverage Determination (NCD). This prohibition does not extend to the results of blood gas tests conducted by a hospital certified to do such tests.

When the arterial blood gas and the oximetry studies are both used to document the need for home oxygen therapy and the results are conflicting, the arterial blood gas study is the preferred source of documenting medical need.

Required qualifying arterial blood gas or oximetry studies must be performed at the time of need. The time of need is defined as during the patient’s illness when the presumption is that the provision of oxygen in the home setting will improve the patient’s condition. For an inpatient hospital patient the time of need is within 2 days of discharge. For those patients whose initial oxygen prescription does not originate during an inpatient hospital stay, the time of need is during the period when the treating practitioner notes signs and symptoms of illness that can be relieved by oxygen in the patient who is to be treated at home.

Patients exhibiting hypoxemia are defined using the clinical criteria below:

Group I:

  • An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88%, taken at rest, breathing room air;or
  • An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88%, 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 greater than normal fall in oxygen level during sleep (a decrease in arterial PO2 more than 10 mm Hg, or decrease in arterial oxygen saturation more than 5%) associated with symptoms or signs reasonably attributable to hypoxemia (e.g., impairment of cognitive processes and nocturnal restlessness or insomnia). In either of these cases, coverage is provided only for use of oxygen during sleep, and then only one type of unit will be covered. Portable oxygen, therefore, would not be covered in this situation; or,
  • An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, taken during exercise [defined as either the functional performance of the patient or a formal exercise test], for a patient who demonstrates an arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, during the day while at rest. In this case, supplemental oxygen is provided for during exercise if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.

Group II: Coverage is available for patients whose arterial PO2 is 56-59 mm Hg or whose arterial blood oxygen saturation is 89%, if there is:

  • 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 AVFL; or,
  • Erythrocythemia with a hematocrit greater than 56%.

In reviewing the arterial PO2 levels and the arterial oxygen saturation percentages specified above, the Medicare Administrative Contractors (MACs) must take into account variations in oxygen measurements that may result from such factors as the patient's age, the patient’s skin pigmentation, the altitude level, or the patient's decreased oxygen carrying capacity.

C. Nationally Non-Covered Indications

The Centers for Medicare & Medicaid Services will not cover oxygen therapy and oxygen equipment in the home in the following circumstances:

  • Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood, and there are other preferred treatments; or,
  • Breathlessness without cor pulmonale or evidence of hypoxemia. Although intermittent oxygen use is sometimes prescribed to relieve this condition, it is potentially harmful and psychologically addicting; or,
  • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities. There is no evidence that increased PO2 improves the oxygenation of tissues with impaired circulation; or,
  • Terminal illnesses unless they affect the ability to breathe.

D. Other

The MAC may determine reasonable and necessary coverage of oxygen therapy and oxygen equipment in the home for patients who are not described in subsection B or precluded by subsection C of this NCD. Initial coverage for patients with other conditions may be limited to the shorter of 90 days or the number of days included in the practitioner prescription at MAC discretion. Oxygen coverage may be renewed if deemed medically necessary by the MAC.

MACs may also allow beneficiaries who are mobile in the home and would benefit from the use of a portable oxygen system in the home to qualify for coverage of a portable oxygen system either (1) by itself, or, (2) to use in addition to a stationary oxygen system.

(This NCD was last reviewed July 2022.)

(See §280.1 and the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," §110.)
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
11263
Coverage Transmittal Link
https://www.cms.gov/files/document/r11263ncd.pdf
Revision History

09/2022 - The purpose of this Change Request (CR) is to revise 240.2 of the National Coverage Determination (NCD) Manual, Publication (Pub.) 100-03, Chapter 1, Part 4 and to inform Medicare Administrative Contractors (MACs) of the changes associated with this NCD, effective September 27, 2001, as amended July 8, 2022. (TN 11587) (CR12877)

05/2022 - Transmittal 11263, dated February 10, 2022, are being rescinded and replaced by Transmittal 11429, dated, May 23, 2022 to extend the implementation date to January 3, 2023. All other information remains the same. (TN 11429) (CR12607)

02/2022 - The purpose of the Change Request is to revise Section 240.2 and Section 240.2.2 of the National Coverage Determination (NCD) Manual (Pub. 100-03), Chapter 1, Part 4, and to inform the Medicare Administrative Contractors (MAC)s of the changes associated with these NCDs effective September 27, 2021. The Centers for Medicare & Medicaid Services finalized revisions to two separate, but medically related, NCDs for oxygen therapy and oxygen equipment in the home. Effective Date: 09/27/2021. (TN 11263) (CR12607)

04/1999 - Incorporated changes on Form-HCFA-484, Certicate of Medical Necessity: Oxygen. Effective date NA. (TN 116) (CR 614)

10/1993 - Revised Medical Documentation section to reflect changes mandated by section 4152 of OBRA 1990. Effective date 01/01/1991.  Revised Laboratory Evidence section to indicate that in situations where arterial blood gas and oximetry studies are both used to document need for oxygen therapy and results are conflicting, arterial blood gas study is preferred service of documenting medical need because results of such studies are considered best evidence of hypoxemia. Effective date 10/27/1993. (TN 66)

06/1989 - Made instructions consistent with §4062 of OBRA 1987. Effective date 01/01/1989. (TN 37)

03/1987 - Clarified coverage criteria for home oxygen use including portable and stationary oxygen systems. Effective date 04/13/1987. (TN 13)
Other

National Coverage Analyses (NCAs)

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Home Use of Oxygen 2 09/27/2021 - N/A You are here
Home Use of Oxygen 1 10/27/1993 - 09/27/2021 View
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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