1.0 HCPCS 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.