E1353 — Regulator
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD), the supplier must receive a signed WOPD before delivery or the claim will be denied.
- Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor on request; claims without appropriate POD will be denied.
- Qualifying blood gas studies must comply with MAC policy standards and be performed by a provider qualified to bill Medicare (Part A provider, laboratory, IDTF, or treating practitioner); suppliers may not perform or pay for qualifying blood gas testing.
- Exercise-based qualification requires documentation in the medical record of three oximetry studies performed within the same testing session: (1) rest without oxygen, (2) during exercise without oxygen, and (3) during exercise with oxygen applied; only test #2 is used for qualification and all three results must be available upon request.
Key Coverage Criteria
- Initial coverage for home oxygen and oxygen equipment is reasonable and necessary only if the treating practitioner ordered and evaluated a qualifying blood gas study performed at the time of need, the study meets the coverage criteria, the study was performed by a treating practitioner or qualified provider/laboratory, and provision of home oxygen is expected to improve the beneficiary’s condition.
- Group I: Coverage if arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% at rest (awake) breathing room air.
- Group I (sleep-only): Coverage if arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% during sleep for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or saturation ≥ 89% while awake, with oxygen reasonable and necessary only during sleep.
- Group I (sleep desaturation from baseline): Coverage if during sleep PO2 decreases >10 mm Hg or oxygen saturation decreases >5% from baseline and the decrease is associated with hypoxemia symptoms (e.g., cognitive impairment, nocturnal restlessness), with oxygen reasonable and necessary only during sleep.
- Group I (exercise): Coverage if arterial PO2 ≤ 55 mm Hg or saturation ≤ 88% during exercise for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or saturation ≥ 89% at rest while awake; in this case portable oxygen is reasonable and necessary only while awake and during exercise.
- Group II: Coverage if arterial PO2 is 56–59 mm Hg or arterial saturation is 89% and the beneficiary has at least one of: dependent edema suggesting congestive heart failure, pulmonary hypertension or cor pulmonale documented by pulmonary artery pressure measurement, gated blood pool scan, echocardiogram, or P pulmonale on EKG, or erythrocythemia with hematocrit > 56%.
2 Active Policies
L33797 — Oxygen and Oxygen Equipment
J19
ANTHEM-CG-DME-18 — CG-DME-18 Home Oxygen Therapy
Related Codes
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