S8121 — Oxygen contents, liquid, 1 unit equals 1 pound
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Physician documentation of severe lung disease or hypoxemia-related symptoms stating expectation of improvement with oxygen therapy.
- Objective blood gas (arterial PO2) or pulse oximetry results demonstrating required thresholds (e.g., PO2 ≤ 55 mm Hg or SpO2 ≤ 88%).
- Documentation that measurements were obtained at rest (awake) while breathing room air.
- Overnight/sleep measurement documentation (arterial blood gas PO₂ or overnight pulse oximetry) demonstrating the nocturnal values and timing (during sleep).
Key Coverage Criteria
- Chronic obstructive pulmonary disease;or
- Cystic fibrosis;or
- Diffuse interstitial lung disease;or
- Pulmonary hypertension;or
- Pulmonary neoplasm (primary or metastatic);or
- Dependent edema secondary to right heart failure;or
2 Active Policies
AMBETTER-CP.MP.190 — Outpatient Oxygen Use
ANTHEM-CG-DME-18 — CG-DME-18 Home Oxygen Therapy
Related Codes
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