Outpatient Oxygen Use

This policy covers initial outpatient/home oxygen therapy (oxygen concentrators and portable oxygen systems) for patients with physician‑documented severe lung disease or hypoxemia—primarily adults ≥18 years but also select pediatric conditions (e.g., chronic lung disease of prematurity, cystic fibrosis, BPD)—when objective criteria are met (Group I: PaO2 ≤55 mm Hg or SpO2 ≤88%; nocturnal/exercise desaturation criteria; Group II: PaO2 56–59 mm Hg or SpO2 ≤89% plus cor pulmonale, dependent edema, or hematocrit >56%). Coverage is limited to initial approvals and requires measurements on room air at rest (or during exercise when applicable), portable systems require documented mobility and qualifying tests not performed only during sleep, inpatient qualifying tests must be within two days of discharge, and age‑specific recertification/documentation rules apply.

"Initial approval of oxygen concentrators and oxygen systems for members/enrollees ≥ 18 years when physician-documented severe lung disease or hypoxemia-related symptoms are expected to improve with..."