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Oxygen
Medicare Coverage Criteria
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Medicare coverage of home oxygen therapy is available only for patients with significant hypoxemia in the chronic stable state provided the following conditions are met:
--The attending or consulting physician has determined that the patient suffers a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy;
--The patient's blood gas levels indicate the need for oxygen therapy;
--and
Alternative treatment measures have been tried or considered and have been deemed clinically ineffective.
Covered Blood Gas Values
Group 1 - Coverage is provided for patients with significant hypoxemia evidenced by any of the following:
An arterial PO2 at or below 55mm. Hg, or an arterial oxygen saturation at or below 88 percent, taken at rest. When a PO2 of greater than 55mm. Hg. is submitted, the service will be denied as not medically necessary unless "Group 2" criteria are met.
An arterial PO2 at or below 55mm Hg., or an arterial saturation at or below 88 percent 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 percent while awake, of a greater than normal fall in oxygen level during sleep (a decrease in arterial PO2 more than 10 mm. Hg., or a decrease in arterial oxygen saturation more than 5 percent) associated with "P" pulmonale n EKG, documented pulmonary hypetension and erythrocytosis. In either of these cases, coberage is provided only for nocturnal use of oxygen.
An arterial PO2 at or below 55 mm. Hg. or an arterial oxygen saturation at or below 88 percent taken during activity for a patient who demonstrates an arterial PO2 at or above 56 mm. Hg. or an arterial oxygen saturation at or above 89 percent, during the day while at rest. In this case, supplemental oxygen is provided for use during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
Group 2 - Coverage is available for patients whose arterial PO2 is 56 to 59 mm. Hg. or whose arterial blood oxygen saturation is 89 percent if any of the following are documented:
Dependent edema suggesting congestive heart failure;
pulmonary hypertension or cor pulmonale, determined by measurment of pulmonary artery pressure, gated blood pool scanechocardiogram, or "P" pulmonale of EKG (P wave greater than 3 mm in standard leads II, II or AVF); or
Erythrocythemia with a hematocrit greater than 56 percent.
Non-Covered Conditions
Conditions for which Oxygen therapy is not considered Medically Necessary by Medicare:
Angina pectoris in the absence of hypoxemia.
Dyspnea without cor pulmonale or evidence of hypoxemia.
Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.
Terminal illnesses that do not affect the respiratory system.
Medicare will presume that home use of oxygen is not medically necessary for patients with arterial PO2 levels at or above 60 mm. Hg., or arterial blood oxygen saturation at or above 90 percent.
Required Documentation: CMN, HCFA Form 484.2
The Certificate of Medical Necessity (CMN) for home oxygen use is HCFA Form 484.2. Federal Law (OBRA 1990) mandates specific sections of this form must be completed by the physician or their staff.
Section A - Contains identifying information, such as patient's name, address, Medicare number and physician or supplier information. This section is usually completed by the supplier.
Section B - This section must be completed by the physician, the physician's employee or another clinician involved in the care of the patient. If someone other than the physician completes Section B, the physician must review the answers to assure their correctness.
Section C - This section must be completed by the supplier prior to sending the CMN to the physician. The supplier's charges and Medicare fee schedule allowance are provided for the physician's information.
Section D - If the information in Section B and the order information in Section C is correct, then the physician signs and dates the CMN and mails it to the supplier. The physician is encouraged to keep a copy of the CMN in the patient's medical record. |
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