Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-11
Topic: Oxygen Concentrators and Related Durable Medical Equipment (DME)
Effective Date: January 1, 2006
Issued Date: January 2, 2006
Date Last Reviewed: 01/2006

General Policy Guidelines

Indications and Limitations of Coverage

Oxygen concentrators (E1390, E1391, E1405, E1406) are covered as durable medical equipment (DME) if the patient's ability to breathe is severely impaired. However, liquid or high pressure oxygen cylinders can provide essentially the same therapy as an oxygen concentrator. The cost of an oxygen concentrator can be substantially more than the use of oxygen cylinders, depending on the amount of oxygen needed by the patient. Oxygen concentrators are cost effective only in situations where the medically appropriate alternative would require the equivalent of at least ten oxygen tanks (size 244 cubic feet) per month. This amount of oxygen could be justified when the patient needs continuous oxygen or frequent administrations resulting in the usage of several hours of oxygen daily. Examples of these conditions are severe congestive heart failure and severe chronic obstructive pulmonary diseases, such as end stage emphysema and pneumoconiosis (Black Lung).

Claims for oxygen concentrators should be reviewed to determine the medical necessity and reasonableness of the equipment for the patient's condition. If it is determined that a less expensive method of administering oxygen is medically appropriate (i.e., oxygen cylinders), payment should be based on the reasonable charge for this alternative method. Oxygen concentrators prescribed on a p.r.n. basis or when the doctor has no record of the patient's oxygen requirements should be denied as not medically necessary.

When both an oxygen concentrator and oxygen cylinders are provided concurrently, payment should be made for the least costly medically appropriate method of providing the oxygen.

When an oxygen concentrator meets the criteria for payment, the DME listed below (or combinations thereof) are also reimbursable when used with such a system to provide therapy adequate for the patient's needs.

Nebulizer (E0580, E0585)

Humidifier (E0550, E0555, E0560)

Humidifier and nebulizer

IPPB unit (Bennet IPPB Machine, Bird Respirator, Hand-E-Vent) (E0500)

IPPB unit, oxygen tank and regulator (some IPPB units operate by their own air compressor driving force systems while others are driven by oxygen tanks with a pre-set regulator set at 50 pounds per square inch)

IPPB unit and humidifier (with or without oxygen tank and regulator (E0500)

Regulated portable oxygen unit (E0430, E0435) or portable oxygen concentrator (E1392)(when prescribed by a physician for an ambulatory patient who can benefit therapeutically from the use of portable oxygen and which allows the ambulatory patient to be away from his stationary home unit for at least one hour)

A regulator (E1353) provided with an oxygen concentrator is not covered because an oxygen concentrator has a built-in regulator and does not require a separate regulator to be operable. However, a regulator/flowmeter is eligible when used with other oxygen equipment, when the patient's ability to breathe is severely impaired. (See Medical Policy Bulletin E-32, Nebulizers, for information on regulators billed with a nebulizer.)

Coverage for DME is determined according to individual or group customer benefits.

NOTE:
Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

Oxygen concentrators, e.g., Marx Oxygen Concentrator (Model 600), provide oxygen in concentrations greater than that available in normal room air. To do this, room air is drawn into the cabinet-like unit where it is filtered and dried and nitrogen is removed. Oxygen-enriched air is then available to the patient through either a nasal cannula or face mask which is connected to an outlet on the unit. Oxygen can be delivered at various flow and concentration ranges depending on the particular model. A typical range is from 2 liters per minute at 90% to 10 liters per minute at 49%.

Procedure Codes

E0430E0435E0500E0550E0555E0560
E0580E0585E1353E1390E1391E1392
E1405E1406    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Medically necessary back-up and support equipment is eligible for payment when the primary item is covered.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

MCM 2100.2B

MCIM 60-9

View Previous Versions

[Version 001 of E-11]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.