Home Oxygen Therapy - DME.O2.100.A

Covers home stationary and portable oxygen for adults and pediatrics with documented hypoxemia (Group 1: resting PaO2 ≤55 mmHg or SaO2 ≤88% or qualifying exercise/sleep desaturation; Group 2: PaO2 ≥56 mmHg or SaO2 ≥89% with signs such as cor pulmonale, pulmonary hypertension, dependent edema, or Hct >55%) and for cluster headache per specified criteria, but excludes use for dyspnea/angina without hypoxemia, desaturation from peripheral vascular disease, and separate billing for accessories or supplies for individually owned equipment. Key requirements: documentation of diagnosis and qualifying ABG/SaO2 (exercise-based coverage requires three oximetry tests in one session: rest without O2, exercise without O2, exercise with O2), portable O2 is not covered if the only qualifying study was sleep, initial rentals are 12 months for Group 1/pediatrics and 3 months for Group 2 (with a repeat blood gas between days 61–90), continued use requires re-evaluation and documented benefit, and limits apply to oxygen contents/supplies.