5 Steps to Qualifying for Home Oxygen Therapy

5 Steps to Qualifying for Home Oxygen Therapy

If you think you have a health condition that would benefit from oxygen therapy, there are several factors to consider before obtaining a prescription from your doctor. Additionally, Medicare, Medicaid and commercial insurance companies may pay for home oxygen, but payment is based on diagnosis, laboratory results and other information as summarized below.

To qualify for home oxygen therapy, consider taking the following 5 steps:

  1. Talk to your doctor about whether you have a qualifying medical condition. This includes a lung condition or other condition that impairs your breathing. You may qualify for home oxygen therapy if you have symptoms and/or findings related to low oxygen levels such as pulmonary hypertension or recurring congestive heart failure due to right-sided heart failure.
  2. Be sure there is well-documented evidence of the qualifying medical condition as mentioned above in your medical file.
  3. Obtain an arterial blood gas study. Typically, to qualify for home oxygen therapy, you must have an arterial blood gas (PaO2) at or below 55 mm Hg or below or an oxygen saturation at or below 88%, taken at rest (awake); or a PaO2 at or below 55 mm Hg, or an oxygen saturation at or below 88%, taken during sleep for a specified duration for a patient who demonstrates a PaO2 at or above 56 mm Hg, or an oxygen saturation at or above 89%, while awake; or a greater than normal fall in oxygen level during sleep (a drop in PaO2 of more than 10 mm Hg, or a decrease in oxygen saturation of more than 5%) associated with symptoms or signs reasonably attributable to low blood oxygen levels; or a PaO2 at or below 55 mm Hg or an oxygen saturation at or below 88%, taken during exercise for a patient who demonstrates a PaO2 at or above 56 mm Hg, or an oxygen saturation at or above 89%, during the day while at rest, with improved results when oxygen is administered.
  1. Obtain a written prescription from a qualified health care professional who has recently examined you (generally within the last month). The prescription should include a diagnosis of the disease requiring the use of home oxygen, the oxygen flow rate in liters per minute and an estimate of the frequency and duration of use (for example, 3 liters per minute, 50 minutes per hour, 12 hours per day) and duration of need (for example, 6 months or lifetime).
  2. Make sure your doctor completes a Certificate of Medical Necessity and/or other forms as required by insurance indicating your diagnosis, length of need, oxygen blood gas level or pulse oximetry reading and the testing facility from which the readings were obtained, how the test was taken (room air, at rest, during exercise or while asleep), portability (if needed), liter flow prescribed, doctor’s signature and date.

Qualifying for Portable Oxygen

If you enjoy the freedom and independence that comes from using oxygen on the go, you may want to consider a portable oxygen concentrator like the Inogen One G3. Medicare will pay for portable oxygen:

  • If you meet the aforementioned daytime testing criteria (when awake), and;
  • Your medical documentation indicates that you’re mobile in your home and would benefit from the use of a portable system.

 

Source:
National Coverage Determination (NCD) for Home Use of Oxygen (240.2). CMS.gov. Accessed 8/24/2015.

By Deborah Leader RN, BSN, PHN

 

One thought on “5 Steps to Qualifying for Home Oxygen Therapy”

  1. Stacy, a very concerned daughter says:

    Trying to understand the guidelines and seeking clarification. Logically, the 88% rule applies to a person with 2 lungs, with reduced capacity or normal capacity and/or CHF.
    Is there specific criteria for a person living with only One Lung, (Second removed due to cancer) operating at <30% capacity, down from 45% a year ago, along with a diagnosis of COPD and quite possibly CHF?
    For several months now, mother is now on 24hr oxygen, using portable O2 in the rehab facility when she goes anywhere outside her room, where she uses a no portable device. Sending her home again (from hospital/rehab) without portable O2, dooms her to the rest of her life being housebound. That is not Living…
    It doesn't seem that the 88% rule/standard would nor could apply…can you please provide some immediate clarification, so a request can be properly submitted to United Healthcare/Medicare? She can't afford this system out of pocket financially, and she can't afford to be housebound the rest of her life either.
    Thank you for your assistance. Hoping for some positive feedback and guidance, as the company servicing her home O2 is being much less than helpful.

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