Home Oxygen Therapy - DME.O2.100.A

Policy covers stationary and portable home oxygen for adults and pediatrics when a diagnosed hypoxia‑related condition meets specific ABG or pulse‑oximetry thresholds for rest, exercise, or sleep (includes cluster‑headache oxygen for adults >18 and pediatric patients >12 meeting criteria) and excludes oxygen for non‑hypoxemic indications (e.g., dyspnea or angina without hypoxemia, peripheral desaturation without systemic hypoxemia, certain terminal illnesses); portable oxygen is not covered if the only qualifying study was during sleep. Key requirements: documented diagnosis plus qualifying ABG/SaO2 by age/scenario, three-part oximetry testing for exercise qualifications, overnight oximetry or defined sleep‑desaturation criteria for sleep qualifications, initial rental 12 months (Group 1/pediatrics) or 3 months (Group 2) with re‑evaluation and documented benefit for continuation, repeat blood gas at days 61–90 for Group 2, mobility and appropriate qualifying study for portable units, and billing limits that bundle contents/accessories with equipment.