Other Services
Chapter 8
Section 10.1
Oxygen And Oxygen Supplies
Issue Date: February 14, 1984
Revision: C-1, March 10, 2017
1.0 HCPCS
PROCEDURE CODES
Level II Codes A4611 - A4629,
E0424 - E0480, E1353 - E1399, E1400 - E1406
2.0 POLICY
2.1 Oxygen
is a prescription medication and the following benefits may be cost-shared:
2.1.1 Oxygen
and the supplies and equipment related to its administration;
2.1.2 Oxygen
in gas (to include oxygen concentrators) and liquid form;
2.1.3 Stationary
and/or portable oxygen units; and
2.1.4 Oxygen therapy for migraine
and/or cluster headaches.
2.2 Oxygen concentrators may be
purchased or cost-shared on a rental basis. If oxygen concentrators
are rented, the Durable Equipment (DE)/Durable Medical Equipment (DME) cost-sharing policy
will not apply even though the purchase price for this equipment
has been reached. Cost-sharing on a rental basis is necessary, as
oxygen concentrators require frequent periodic maintenance and frequent
checks to ensure that the liter flow setting of the oxygen concentrator
has not been altered.
2.3 If the initial prescription
shows an indefinite or lifetime need for oxygen, a new prescription
is not required as long as the diagnosis substantiates its continued
use.
3.0 EXCLUSIONS
The following are not covered:
3.1 Oxygen
(95%) and carbon dioxide (5%) inhalation therapy for inner ear disease.
The therapeutic benefit derived from this procedure is not established.
3.2 The purchasing
of maintenance agreements for oxygen equipment.
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