OXYGEN CONCENTRATOR & PORTABLE CONCENTRATOR - (E1390/E1392t)

Face to Face/Chart Note must explain the medical need:

Patient is only covered if they have difficulty raising and clearing secretions secondary

1. Severe lung disease, such as COPD, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm; or

2. Hypoxia related symptoms; or

3. Findings that might be expected to improve with oxygen therapy; AND

   • The patient is not experiencing exacerbation of this underlying lung disease or another acute condition impacting their 02 saturation.

4. Qualifying Testing Requirements (MUST BE IN A CHRONIC AND STABLE STATE/CANNOT BE DONE IN ED):

   • In Patient: Testing is the most recent qualifying test performed no earlier than 48 hours prior to discharge.

   • Out Patient: Most recent qualifying test performed within 30 days prior to initiating home oxygen therapy.

PORTABLE TANKS - (E0431)

1. Patient must be mobile within the home; AND

2. Must include the means of the oxygen delivery (cannula or mask), liters per minute and duration of use.

Testing:

1. On room air at rest (awake); must be below 88% or

2. For at least 5 minutes taken during sleep

3. During Exercise - 3 conditions must be met within the same session:

• Testing on room air no oxygen

• Testing during exercise/ambulation without oxygen

• Testing during exercise with oxygen applied

Prescription Requirements: Must include type of oxygen to be dispensed and the means of oxygen delivery (via cannula or mask), liters per minute and the duration of use. I.E. Oxygen 2 lpm via cannula continuously. Cannot use PRN.