Supplemental oxygen therapy is a medical treatment designed to provide patients with an increased concentration of oxygen to support respiratory function. This therapy is commonly prescribed for individuals dealing with chronic respiratory conditions, such as Chronic Obstructive Pulmonary Disease (COPD) or pulmonary fibrosis, which impair the body’s ability to absorb sufficient oxygen from the air. Obtaining coverage for home oxygen equipment through an insurance provider involves a structured process. This process requires documentation and coordination between the patient, the physician, and the equipment supplier to ensure the prescription meets all regulatory and payer guidelines.
Establishing Medical Necessity
Oxygen is classified as a prescribed medication, meaning it cannot be acquired without an order from a physician or pulmonologist. The first step in securing coverage is a face-to-face evaluation where the doctor determines if the patient’s condition warrants supplemental oxygen. This evaluation must confirm that alternative treatments, such as inhalers or medications, have been considered or were found to be ineffective in managing the patient’s oxygen levels.
To establish medical necessity for insurance coverage, specific clinical testing is required. This usually involves pulse oximetry, which measures oxygen saturation (SpO2), or an Arterial Blood Gas (ABG) test, which measures the partial pressure of oxygen (PaO2). Guidelines generally require that a patient’s SpO2 must be 88% or lower, or the PaO2 must be 55 mm Hg or lower, while the patient is awake and at rest breathing room air. If the SpO2 is 89%, coverage may still be approved if the patient also has a secondary qualifying condition, such as pulmonary hypertension or congestive heart failure. These tests must be performed while the patient is in a chronic stable state, not experiencing a temporary acute illness or severe flare-up.
Choosing the Right Equipment
Once the prescription is issued, the patient and physician must select the most appropriate delivery system based on the required flow rate and the patient’s lifestyle. The three primary types of oxygen delivery systems are stationary oxygen concentrators, portable oxygen concentrators (POCs), and compressed gas cylinders.
Stationary Concentrators
Stationary oxygen concentrators are large, electric-powered units designed for continuous, high-flow use within the home. They provide an uninterrupted supply of oxygen by filtering room air. These devices are highly reliable and eliminate the need for tank refills, making them preferred for patients requiring a high flow rate. However, they restrict mobility to the length of the tubing.
Portable Concentrators
Portable oxygen concentrators (POCs) are lightweight, battery-operated units. POCs allow patients to maintain an active lifestyle outside the home. Their oxygen purity, usually 90% to 95%, can be affected by the flow rate, and their use is limited by battery life.
Compressed Gas Cylinders
Compressed gas cylinders, or oxygen tanks, store oxygen under high pressure and are independent of an electrical source. Tanks deliver oxygen with a purity often exceeding 99.6% and are a reliable choice for emergency backup or very high flow rates. Cylinders are heavy, require frequent exchange or refilling by a supplier, and the finite supply requires constant monitoring of the remaining volume.
Navigating Insurance and Suppliers
Securing the equipment involves coordinating with a Durable Medical Equipment (DME) company. These companies provide oxygen equipment under most insurance plans, including Medicare Part B. After the physician writes the order, the DME supplier submits the request to the insurance company, a step that often requires prior authorization.
Prior authorization is a formal approval process where the insurer reviews the physician’s documentation to confirm that medical necessity criteria are met before delivery. The physician must complete a Certificate of Medical Necessity (CMN) form detailing the patient’s diagnosis, qualifying test results, and the prescribed flow rate and duration of use. The DME supplier is responsible for submitting the CMN with the prior authorization request, but they cannot complete the clinical sections of the form.
For long-term oxygen users, the equipment is typically provided on a rental basis. Medicare Part B covers the rental fee for 36 months. Following this period, the DME supplier must continue to provide the equipment and maintenance for an additional 24 months, totaling five years of use. Patients remain responsible for cost-sharing, which usually includes a deductible and a 20% coinsurance of the Medicare-approved amount.
Safe Handling and Home Use
Once the oxygen equipment is set up in the home, strict safety protocols must be followed to mitigate the risk of fire. Oxygen does not burn, but it significantly supports and intensifies combustion, meaning a fire can start and spread quickly in an oxygen-rich environment.
Users must adhere to several safety rules:
- No one should smoke near the oxygen equipment, including traditional cigarettes and e-cigarettes.
- All oxygen sources must be kept at least 6 to 10 feet away from any heat source, such as gas stoves, heaters, or fireplaces.
- Avoid applying petroleum-based products, like certain creams or ointments, to the face or upper chest while using oxygen, as these materials are highly combustible.
- Concentrators must be placed in a well-ventilated area, avoiding confined spaces like closets, to prevent overheating.
- Compressed gas cylinders should always be stored upright and secured with a chain or stand to prevent falls.
Regular maintenance involves routinely checking the oxygen tubing for cracks or leaks and cleaning or replacing the air intake filters as recommended by the manufacturer.