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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