Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-13
Topic: Oxygen Related Durable Medical Equipment (DME)
Effective Date: October 1, 2005
Issued Date: October 3, 2005
Date Last Reviewed: 10/2005

General Policy Guidelines

Indications and Limitations of Coverage

See the Table Attachment below for a list of commonly reported oxygen-related items processed as durable medical equipment.

Coverage for durable medical equipment 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).

Procedure Codes

A4608A4620E0430E0441E0442E0443
E0444E0550E0555E0560  

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Benefits are available for a backup oxygen cylinder in case of a power failure.

Benefits are available for a backup oxygen tank in case of a power failure.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 001 of E-13]

Table Attachment

OXYGEN RELATED DURABLE MEDICAL EQUIPMENT (DME)
Item Coverage Status
Face Masks (oxygen)
(A4620)		 Covered
Humidifiers (oxygen)
(E0550-E0560)		 Covered if a medical humidifier has been prescribed for use in connection with medically necessary durable medical equipment for purposes of moisturizing oxygen.
LC-3 Oxygen System Institutional oxygen system; not a rental type item.
Oxygen
(E0441-E0444)		 Covered if the oxygen has been prescribed for use in connection with medically necessary durable medical equipment.
Oxygen Conserving Device Reimbursement may be made as a medically necessary accessory only when used as part of a covered home oxygen system.
Oxygen Cylinders
(Linde Reservoir Unit)		 Deny-not primarily medical in nature. However, reimbursement may be made for the cylinder contents (oxygen). Charges in excess of the amount which can be allowed for the cylinder contents should be denied.
Oxygen Tank Noncovered except as an incidental cost of providing oxygen. By itself, it is not medical equipment, serves neither a therapeutic nor diagnostic function.
Oxygen Tents
(E0455)		 Covered if patient's ability to breathe is severely impaired.
Portable Oxygen Systems
(E0430)
(Lif-O-Gen Tanks, Linde Oxygen Walker System, Madasphere Portable Oxygen Unit, Oxycane, Port-O-Matric, S.O.S. Emergency Oxygen Inhalator)		 1. Regulated (adjustable flotation rate)
Covered on individual consideration basis.
Refer all claims for medical review.

2. Preset (flow rate not adjustable)
Deny
Spare Tanks of Oxygen Deny-convenience or precautionary supply.
Transtracheal Oxygen Catheter
(A4608)		 A small flexible tube placed into the trachea by an outpatient surgical procedure when it is indicated a patient needs improved mobility, the patient has complications from nasal prongs, or the patient exhibits corpulmonale (416.0-416.9), erythrocythemia (207.00, 207.01), or refractory hypoxemia (799.02) on nasal oxygen.

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.