Summary
Oxygen and oxygen accessories are considered durable medical equipment, and coverage is subject to the member's DME benefit. Oxygen therapy is medically necessary for severe lung disease defined by a resting PaO2 below 55 mm Hg (or 60 mm Hg with heart failure), an O2 saturation below 90 percent, or symptoms of oxygen deprivation such as impaired cognitive processes, restlessness or insomnia, and for cluster headaches when other treatment fails. Oxygen therapy is not medically necessary for angina or breathlessness without evidence of hypoxemia, severe peripheral vascular disease with clinically evident desaturation, or terminal illnesses that do not affect the lungs.
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What to do
Action · 8 steps
01Oxygen and oxygen supplies are covered for appropriately selected patients only when a physician prescribes oxygen within 30 days of the documentation, and the prescription must specify the diagnosis requiring oxygen, oxygen concentration and flow rate, frequency of use (for intermittent or leave-in therapy, time limits and specific indications for starting and stopping), method of delivery, and duration of use.
02An indefinite prescription is periodically reviewed to determine whether a medical need continues, and patients on long-term oxygen therapy are periodically re-evaluated to assess whether hypoxemia persists.
03Do not bill oxygen prescribed for use as needed (PRN), and do not bill portable oxygen systems for patients who qualify for oxygen solely on blood gas studies obtained during sleep.
04Oxygen furnished in facilities expected to supply it, setup or installation of respiratory support systems, preset regulators used with portable systems, regulators permitting a flow rate above 8 liters per minute, and an excessive number of spare tanks are not medically necessary.
05Accessories such as nasal cannula, mask, tubing, tent, humidifier, nebulizer, regulator, flow meter, maxi-mist and oxygen gauge are an integral part of the rental or purchase allowance for the delivery system, and carts, racks or stands are included in the supplier's fee and are not covered separately.
06If more than one tank is required in a month, the cost of the oxygen in two or more tanks is covered, but rental is paid for the initial tank only.
07E tanks normally do not qualify as a portable oxygen system, although an E tank may be medically necessary when the patient has a stationary tank at bedside.
08Repair or replacement of components during rental is the responsibility of the DME supplier, and purchased equipment is repaired or replaced only within a reasonable time of purchase, subject to its lifetime expectancy.
Codes mentioned
A4608A4615A4616A4617A4618A4619A4620A4623A7520A7521A7522A7525E0424E0425E0430E0431E0433E0434E0435E0439E0440E0441E0442E0443E0444E0447E0455E0550E0555E0560E0580E1353E1372E1390E1391E1392E1405E1406K0738S8120S8121E0445E1354E1355G44.001G44.009G44.011G44.019G44.021G44.029I27.81R09.02Z99.81
Original notice
Oxygen
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Related changes
See all Blue Cross & Blue Shield of Mississippi changes →Durable Medical Equipment (DME)MediumNo effective date · Medical PolicyPulse Oximetry for Home UseMediumNo effective date · Medical PolicyPulmonary Arterial HypertensionMediumEffective Oct 1, 2025 · Medical PolicyRespiratory DevicesMediumNo effective date · Medical PolicyBrowse every Blue Cross & Blue Shield of Mississippi change in the policy list
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Blue Cross & Blue Shield of Mississippi policiesMS policy changesPulmonologyInternal MedicineCode A4608Code A4615Code A4616Code A4617Code A4618Code A4619Code A4620Code A4623Code A7520Code A7521Code A7522Code A7525Code E0424Code E0425Code E0430Code E0431Code E0433Code E0434Code E0435Code E0439Code E0440Code E0441Code E0442Code E0443Code E0444Code E0447Code E0455Code E0550Code E0555Code E0560Code E0580Code E1353Code E1372Code E1390Code E1391Code E1392Code E1405Code E1406Code K0738Code S8120Code S8121Code E0445Code E1354Code E1355Code G44.001Code G44.009Code G44.011Code G44.019Code G44.021Code G44.029Code I27.81Code R09.02Code Z99.81