Rule 5160-10-13 | DMEPOS: oxygen.
(A) Definitions.
(1) "Blood gas study" is the measurement of such characteristics of blood as the partial pressure of oxygen (PO2) or oxygen saturation. The term applies either to pulse oximetry or to an arterial blood gas (ABG) study.
(2) "Group I" and "group II" criteria are sets of clinical indicators used to determine the coverage of oxygen without prior authorization.
(a) Group I criteria.
(i) If the individual is tested while awake and at rest, either of the following measures applies:
(a) Arterial PO2 of fifty-five millimeters of mercury (mm Hg) or less; or
(b) Arterial oxygen saturation at or below eighty-eight per cent.
(ii) If the individual is tested while ambulating, either of the following measures applies:
(a) Arterial PO2 of fifty-five mm Hg or less during ambulation without oxygen, with documented improvement during ambulation with oxygen; or
(b) Arterial oxygen saturation at or below eighty-eight per cent during ambulation without oxygen, with documented improvement during ambulation with oxygen.
(iii) If the individual is tested while asleep, any of the following measures applies:
(a) Arterial PO2 of fifty-five mm Hg or less;
(b) Arterial oxygen saturation at or below eighty-eight per cent;
(c) A decrease in arterial PO2 of more than ten mm Hg, associated with symptoms of or signs reasonably attributable to hypoxemia; or
(d) A decrease in arterial oxygen saturation of more than five per cent, associated with symptoms of or signs reasonably attributable to hypoxemia.
(b) Group II criteria.
(i) Either of the following measures applies:
(a) Arterial PO2 of at least fifty-six mm Hg and not more than fifty-nine mm Hg; or
(b) Arterial oxygen saturation at or above eighty-nine per cent.
(ii) In addition, at least one of the following conditions applies:
(a) Dependent edema suggestive of congestive heart failure;
(b) Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or the presence of P pulmonale on an EKG; or
(c) Erythrocythemia with a hematocrit greater than fifty-six per cent.
(3) "Group III criteria" is an informal designation for any other clinical indicators used to determine, through the prior authorization (PA) process, the medical necessity of oxygen. Such indicators include but are not limited to the following examples:
(a) Cluster headaches; or
(b) An illness for which a public health emergency has been declared.
(4) "Transfill unit" is a device that transfers oxygen from a source such as an oxygen concentrator to portable tanks.
(B) Providers.
(1) The following eligible medicaid providers may prescribe oxygen:
(a) A physician;
(b) An advanced practice registered nurse with a relevant specialty; or
(c) A physician assistant.
(2) The following eligible medicaid providers may supply oxygen:
(a) A durable medical equipment (DME) provider;
(b) A pharmacy;
(c) A physician;
(d) An advanced practice registered nurse with a relevant specialty;
(e) A physician assistant; or
(f) An ambulatory health care clinic.
(3) The following eligible medicaid providers may receive medicaid payment for submitting a claim for oxygen:
(a) A DME provider;
(b) A pharmacy;
(c) A physician;
(d) An advanced practice registered nurse with a relevant specialty;
(e) A physician assistant;
(f) An ambulatory health care clinic; or
(g) A professional medical group.
(C) Certification of medical necessity.
(1) Payment for oxygen can be made only if a prescriber certifies that the oxygen is medically necessary for an individual. A completed certificate of medical necessity (CMN) needs to be signed and dated by the prescriber before a claim is submitted. The default form is the ODM 01909, "Certificate of Medical Necessity: Oxygen" (rev. 11/2024).
(2) On the CMN, the prescriber specifies an estimated length of need (certification period), which may range from one month to a lifetime.
(a) For an individual with a condition meeting group I criteria, each certification period is limited to a maximum of twelve months after the first date of service.
(b) For an individual with a condition meeting group II criteria, the certification period immediately following the first date of service is limited to a maximum of three months, and each certification period thereafter is limited to a maximum of twelve months.
(3) An initial CMN is used to document certification for new service.
(a) An initial CMN needs to be completed if oxygen has not been supplied under medicaid to an individual for at least two full calendar months.
(b) The individual needs to be seen and evaluated by a prescriber, and a blood gas study is needed.
(i) If the individual is a hospital inpatient or resident of a long-term care facility (LTCF), the most recent blood gas study performed within forty-eight hours before discharge is used.
(ii) Otherwise, the most recent blood gas study performed within the preceding twelve months may be used.
(4) A renewing CMN is used to extend certification.
(a) If the need for oxygen was established through a respiratory study in which a positive airway pressure device was shown to be effective only when supplemental oxygen was administered simultaneously, then the need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further respiratory study is needed to confirm a continued need for oxygen.
(b) Otherwise, the provider obtains a new prescription within ninety days before the end of the existing certification period (or, for lifetime certification, within ninety days before the expiration of the current prescription). No new blood gas study is needed.
(5) A revised CMN is used to modify an existing certification.
(a) The most recent blood gas study performed within thirty days before the revision date is used as the basis for any of the following modifications:
(i) The prescribed maximum flow rate has changed. If the new rate is greater than four liters per minute (LPM), then a new blood gas study needs to be performed while the individual is receiving four LPM.
(ii) Certification is being given for a portable oxygen delivery system to supplement a stationary system for which certification was previously given. If the most recent qualifying study was performed during sleep, then a new blood gas study needs to be performed while the individual is awake, either at rest or ambulating.
(b) No additional blood gas study is needed for the following modifications:
(i) There is a new prescriber, but the oxygen order is the same.
(ii) There is a new provider, and the new provider does not have the most recent CMN.
(D) Coverage.
(1) Payment may be made for oxygen supplied in the following forms:
(a) Stationary gaseous oxygen system (private residence only);
(b) Portable gaseous oxygen system (private residence only);
(c) Stationary liquid oxygen system (private residence only);
(d) Portable liquid oxygen system (private residence only);
(e) Oxygen contents, gaseous, including supplies (LTCF only);
(f) Oxygen contents, liquid, including supplies (LTCF only);
(g) Oxygen concentrator, single delivery port;
(h) Oxygen concentrator, dual delivery port;
(i) Portable oxygen concentrator (private residence only); and
(j) Transfill unit (private residence only).
(2) Separate payment for a portable oxygen delivery system may be made in addition to payment for a stationary system only if the following criteria are met:
(a) The individual has a demonstrable need for a separate portable system, either to maintain mobility in a private residence or to accomplish out-of-home activities;
(b) The individual's stationary oxygen delivery system cannot be used as a portable delivery system; and
(c) The prescribed oxygen flow is four LPM or less. If the prescribed oxygen flow is greater than four LPM, then no separate payment is made for the portable oxygen delivery system.
(3) PA is not needed when a supplier has obtained a properly completed CMN and furnishes oxygen to an individual either who has a condition that meets group I or group II criteria or who is a resident of a LTCF.
(4) PA is needed when a supplier has obtained a properly completed CMN and furnishes oxygen to an individual who has a condition that meets neither group I nor group II criteria and who is not a resident of a LTCF. If authorization is given, then the length of the authorization period will be based on medical necessity and cannot exceed the timeframe indicated by the prescriber. The PA request needs to include a copy of the completed CMN.
(5) Oxygen is not medically necessary if it is prescribed for any of the following conditions:
(a) Angina pectoris in the absence of hypoxemia;
(b) Dyspnea without cor pulmonale or evidence of hypoxemia;
(c) Severe peripheral vascular disease that results in clinically evident desaturation in one or more extremity but does not produce systemic hypoxemia; or
(d) A terminal illness that does not affect the respiratory system.
(E) Claim payment.
(1) Payment for oxygen is made on a monthly basis and includes the following related items and services:
(a) Setup and instruction on use;
(b) Equipment and supplies;
(c) Maintenance and repair, including the replacement of any part or attachment (such as tubing, cannula, mask, or filter) that is integral to the oxygen system or the operation of the system;
(d) Transportation or delivery charges;
(e) Emergency service, including the provision of backup equipment and supplies;
(f) Oxygen consumed (when applicable); and
(g) Equipment monitoring visits.
(2) The maximum payment for oxygen is the amount set forth in the appendix to this rule. When the prescribed oxygen flow is greater than four LPM, the payment amount is increased by fifty per cent.
Last updated November 4, 2024 at 8:43 AM
Supplemental Information
Amplifies: 5164.02
Five Year Review Date: 11/4/2029
Prior Effective Dates: 4/7/1977, 12/21/1977, 12/30/1977, 1/1/1980, 3/1/1984, 5/1/1990, 6/20/1990 (Emer.), 9/5/1990, 2/17/1991, 5/25/1991, 4/1/1992 (Emer.), 7/1/1992, 3/31/1994, 1/1/1995, 8/1/1995, 8/1/1998, 10/11/2001, 11/1/2007, 7/31/2009 (Emer.), 10/29/2009, 8/2/2011, 12/31/2013, 7/16/2018, 7/1/2021