Section 427.441 - Clinical Requirements: Oxygen Therapy Equipment(A)Requirements for Coverage. Oxygen therapy equipment is reimbursable for the treatment of severe lung diseases (for example, chronic bronchitis, emphysema, and interstitial lung disease) that cause hypoxemia and where oxygen therapy can reasonably be expected to correct the patient's hypoxemia .(B)Laboratory Evidence.(1) The initial prior-authorization request for oxygen therapy equipment in the home must include laboratory evidence of chronic hypoxemia. This evidence must be in the form of an arterialblood gas analysis (PaO 2 : 55 torr while breathing room air) or an oximetry reading (SaO 2 : 88% while breathing room air).(2) The arterial blood gas analysis or oximetry reading must reflect the recipient's baseline and stable blood-oxygen status. The reading must be performed as close as possible to the time of discharge from the hospital or close to the set up time of the equipment in the home.(3) The test for evidence of hypoxemia must be performed while the recipient is in a resting state and breathing room air. Prior authorization will be deferred for services based on tests performed while the recipient is breathing supplemental oxygen unless the physician can certify that removing the oxygen from the patient could be life threatening.(C)Evidence of Hypoxemia. One or both of the following test results are sufficient evidence of hypoxemia if they are performed while the patient is breathing room air and are in association with corpulmonale, congestive heart failure, or erythrocythemia with a hematocrit of more than 56: (1) PaO2 = 56 - 59 torr, or(D)Qualification for Supplemental Oxygen Therapy Equipment. Some recipients may not qualify for oxygen at rest, but may qualify for supplemental oxygen during ambulation, sleep, or exercise. Oxygen therapy equipment may be reimbursable during these specific activities when SaO 2 is demonstrated to fall to 88% or less.(E)Prescriptions for Supplemental Oxygen Therapy Equipment.Prescriptions for noncontinuous supplemental oxygen therapy must include the following information:(1) the number of hours per day supplemental oxygen will be required;(2) the activity during which the prescribed supplemental oxygen will be utilized; and(3) the total hours of use per day. Example:
Nasal cannula (2 liters/minute): 8 hours sleeping + 2 hours walking / 10 hours total
(F)Requirements for Portable Oxygen. A patient meeting all of these requirements may qualify for a portable oxygen system. The prescriber must document that the recipient's activities take him or her beyond the functional limits of the stationary system.(G)Reasons for Noncoverage. Oxygen therapy shall not be approved for the following conditions:(1) angina pectoris in the absence of hypoxemia;(2) breathlessness without corpulmonale or evidence of hypoxemia;(3) peripheral vascular disease resulting in desaturation in one or more extremities without evidence of central hypoxemia; and(4) terminal illness that does not involve the lungs.(H)Required Documentation. The provider must submit the following documentation for reimbursement for oxygen therapy: (1) a written prescription pursuant to 130 CMR 427.408;(2) prior authorization pursuant to 130 CMR 427.409; and(3) documentation of the medical necessity for oxygen therapy in the treatment of hypoxemia (see 130 CMR 427.407(D) and 450.208 ).