Does Medicare Cover Portable Oxygen Machines?

Medicare covers portable oxygen machines as durable medical equipment (DME) for individuals with qualifying medical needs. Coverage is subject to a doctor’s determination of medical necessity and Medicare guidelines for oxygen therapy. This supports beneficiaries requiring supplemental oxygen to manage chronic conditions and maintain quality of life.

Medicare Coverage Criteria for Portable Oxygen Machines

Medicare covers portable oxygen concentrators when a doctor certifies them as medically necessary for treating certain conditions. Patients must have severe lung disease or other hypoxia-related symptoms expected to improve with oxygen therapy, such as chronic obstructive pulmonary disease (COPD), pneumonia, asthma, heart failure, and cystic fibrosis.

To establish medical necessity, specific testing is required. This involves arterial blood gas (ABG) studies or oximetry readings, demonstrating low oxygen levels at rest or during exertion. A common criterion is an arterial PO2 at or below 55 mmHg or an oxygen saturation level at or below 88% on room air. Testing must be performed while the patient is stable and within 30 days prior to the prescription.

The medical record must contain documentation supporting the need for oxygen therapy, including diagnosis, duration of the condition, and clinical course. It must also show that alternative treatment measures were tried or considered and deemed ineffective. For portable oxygen, documentation must indicate the patient is mobile within the home and that the qualifying blood gas study was performed while awake or during exercise.

Medicare Parts and Patient Costs

Portable oxygen machines are classified as Durable Medical Equipment (DME) and covered under Medicare Part B. Part B covers rental of oxygen equipment and accessories for home use, including the concentrator, tubing, mouthpieces, and necessary accessories.

Beneficiaries face out-of-pocket costs, including the annual Part B deductible. After meeting the deductible, Medicare generally pays 80% of the Medicare-approved amount for equipment rental, with the beneficiary responsible for the remaining 20% coinsurance. For example, a $200 monthly rental would mean a $40 payment per month after the deductible is met.

Medicare’s rules for oxygen equipment specify a 36-month rental period. During this period, monthly rental payments cover the equipment, oxygen contents, supplies, and maintenance. After 36 months, the supplier must continue to provide the equipment, contents, supplies, and maintenance for an additional 24 months, completing a five-year service period, as long as there is a continued medical need. The supplier retains ownership throughout this five-year period.

Medicare Advantage Plans (Part C) also cover portable oxygen concentrators, as they must provide at least the same level of benefits as Original Medicare. These plans may have different cost-sharing structures, network requirements, and prior authorization rules. Patients should consult their specific plan details to understand their financial responsibilities.

Steps to Obtain a Portable Oxygen Machine

Obtaining a portable oxygen machine with Medicare coverage begins with a medical evaluation from a treating physician or qualified healthcare professional. This evaluation includes an in-person visit where the physician assesses the patient’s respiratory condition and determines medical necessity for oxygen therapy. The medical record must document the need for oxygen, including results from blood gas studies or oximetry tests that meet Medicare’s criteria.

Following the evaluation, the physician issues a prescription or detailed written order for the portable oxygen machine. This order specifies the equipment type, prescribed oxygen flow rate, and duration of need. The physician also completes a Certificate of Medical Necessity (CMN), which summarizes the medical justification for oxygen therapy. These documents are for the supplier to submit a claim to Medicare.

The next step involves selecting a Medicare-approved Durable Medical Equipment (DME) supplier. Beneficiaries can locate approved suppliers through the Medicare.gov website or by calling 1-800-MEDICARE. Choose a supplier that accepts Medicare assignment, meaning they agree to accept Medicare’s approved amount as full payment. The supplier will work with the patient’s physician to gather all required documentation, including the prescription and supporting medical records, before delivering the equipment. The supplier is then responsible for submitting claims directly to Medicare.

What to Do if Coverage is Denied

If Medicare denies coverage for a portable oxygen machine, beneficiaries receive an official notice, such as a Medicare Summary Notice (MSN) or an Explanation of Benefits (EOB), detailing the denial reason. This notice also outlines the beneficiary’s right to appeal the decision. Understand the reason for denial, which could range from insufficient medical documentation to issues with supplier enrollment.

The Medicare appeals process consists of several levels. The first level is a Redetermination, involving a review by the Medicare Administrative Contractor (MAC) that made the initial decision. A request for redetermination must be filed in writing, generally within 120 days from the date of receipt of the denial notice. Include any additional medical documentation or information that supports the claim.

If the redetermination is unfavorable, the beneficiary can proceed to the second level of appeal, a Reconsideration by a Qualified Independent Contractor (QIC). This request must be filed within 180 days of receiving the redetermination decision. Should the QIC’s decision also be unfavorable, further appeal levels include a hearing before an Administrative Law Judge (ALJ), a review by the Medicare Appeals Council, and judicial review in a Federal District Court. Throughout the appeals process, beneficiaries can seek assistance from their doctor, the DME supplier, or a State Health Insurance Assistance Program (SHIP) for guidance and support.