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Oxygen Documentation & Guidelines

Oxygen therapy is covered for patients when the treating physician has determined the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy.

Medical records supporting that the patient has been seen within 30 days prior to ordering the oxygen and the treating physician has considered alternative treatment measures and demeed them clinically ineffective; AND

The patient has had a blood gas study that meets one of the following criteria:

The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services (blood gas studies performed by a supplier are not acceptable); AND

The qualifying blood gas study was obtained under one of the following conditions:

The qualifying blood gas study was the most recent study obtained prior to the initial date indicated in Section A of the CMN and this study was obtained within 30 days prior to the Initial State; AND

The patient was seen and evaluated by the treating physician within 30 days prior to the date of the initial certification; AND

Alternative measures have been tried or considered and deemed clinically ineffective.

Group I criteria include any of the following:

[Note: All three qualifying blood gas study readings should be taken during a single testing session. The exercise blood gas reading is the number that should be recorded on the CMN. However, all three readings must be recorded in the medical record. Medical records must support the patient is mobile within the home.]

Group II criteria include the presence of (a) arterial PO2 of 56-59mm Hg or an arterial blood oxygen saturation of 89% at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and (b) any of the following:

Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. The patient would have to be retested between the 61st and 90th day following Initial Certification.

Documentation of Continued Medical necessity is required; the patient must be seen within 90 days prior to the recertification date of the CMN for Group I patients. Group II patients must be tested between the 61st and the 90th day after the date of the initial CMN. All patients after the recertification should be seen at least every 12 months and medical records updated to show continued need for the oxygen.

The physician's signature on the medical record must meet signature requirements:

NHIC, Corp.. Local Coverage Determination (LCD) for Oxygen and Oxygen Equipment (L11468). Retrieved July 9, 2012 from

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