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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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