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TRICARE Policy Manual 6010.60-M, April 1, 2015
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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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