Article Detail - JD DME

Posted November 22, 2013

Medicare does not provide reimbursement for home oxygen as a treatment of Obstructive Sleep Apnea (OSA). However many beneficiaries with OSA have co-existing chronic pulmonary conditions that would justify coverage of home oxygen, after appropriate titration polysomnogram (PSG) and meeting the requirements specified in the Oxygen LCD. Both the Oxygen LCD and the Positive Airway Pressure Devices (PAP) LCD contain detailed information about the testing necessary to justify payment of home oxygen. This FAQ discusses some of the common scenarios seen. Refer to the LCDs for detailed information about coverage of PAP and home oxygen.

Following the Q&A, an algorithm is included to assist in analyzing OSA / home oxygen testing scenarios. Note that the algorithm does not itemize all coverage requirements for OSA or home oxygen. It is intended as an overview of qualification testing. Refer to the LCDs for detailed information about payment rules.

1. A beneficiary has a diagnosis of obstructive sleep apnea (OSA) and does not meet any of the Oxygen LCD Group I or Group II criteria, yet their physician has prescribed home oxygen therapy. In this instance, would the home oxygen be covered?

Response: No, home oxygen would not be covered. In order for home oxygen to be reimbursed the payment rules described in the oxygen policy must be met.

2. A beneficiary has a diagnosis of OSA and demonstrated oxygen desaturation during a titration polysomnogram (PSG) as described in the oxygen LCD. Following diagnosis and optimal treatment of the OSA during the titration PSG, it is discovered that the beneficiary is not using the PAP device as prescribed (refused the device, is non-compliant, etc.) but the physician has prescribed oxygen for use during sleep. In this instance, would the home oxygen be covered?

Response: Yes, home oxygen is covered. For beneficiaries with OSA, the titration PSG is used to:

a. Assure that the OSA is optimally treated thus satisfying the Oxygen LCD "chronic stable state" requirement, and

b. Determine that the remaining hypoxia meets the Oxygen LCD qualification threshold.

Beneficiary compliance with treatment after testing is not a factor in determining eligibility for payment of home oxygen.

Note: This answer assumes that OSA is the only other concurrent condition that could affect blood oxygen levels and that the underlying lung disease is adequately treated and stable as required by the Oxygen LCD.

3. A beneficiary has a diagnosis of OSA and demonstrated oxygen desaturation during a titration polysomnogram (PSG) as described in the oxygen LCD; however, the beneficiary is unable to tolerate PAP therapy during the titration PSG. The physician does not prescribe PAP but rather prescribes oxygen therapy. In this instance, would the home oxygen be covered?

Response: No, home oxygen is not covered. Oxygen is not the primary treatment for OSA. The Oxygen LCD requires that the beneficiary is optimally treated with respect to their OSA thus satisfying the Oxygen LCD "chronic stable state" requirement.

4. A beneficiary has a diagnosis of OSA and has been diagnosed with a chronic, severe lung disease (i.e., COPD, emphysema). The beneficiary has tried PAP, other treatment options, such as an oral appliance, weight loss and surgery. All treatments have been determined by their physician to be unsuccessful. With no active OSA treatment, the beneficiary continues to desaturate at night (< 88% for 5 total minutes or more), as evidenced by overnight oximetry testing. The physician has prescribed home oxygen for use at night. In this instance, would the home oxygen be covered?

Response: This question actually has insufficient information to determine whether home oxygen might be eligible for payment. What is missing is information about the type of testing done. A titration PSG must have been performed. During the titration phase, optimal treatment with the PAP device must have been achieved. Only after optimal treatment with a PAP device can an assessment of the remaining hypoxia (if any) be done. For the beneficiaries remaining hypoxic while receiving optimal PAP therapy, home oxygen may be covered if the oxygen testing reaches the levels required by the oxygen LCD. Compliance with treatment for OSA is not a determining factor for qualification of home oxygen.

5. A beneficiary has a diagnosis of OSA and has been diagnosed with a chronic, severe lung disease (i.e., COPD, emphysema). During a titration PSG that lasted more than 2 hours, the beneficiary was titrated with PAP to an AHI/RDI of <10 events per hour, yet continued to desaturate below 88% for more than five total minutes. The physician has prescribed oxygen for use in conjunction with the PAP. In this instance, would the home oxygen be covered?

Response: Yes, home oxygen would be covered. The question restates the titration PSG requirements described in the LCDs. A titration PSG meeting these requirements can be used for qualification of home oxygen.

6. A beneficiary has a diagnosis of OSA and has been diagnosed with a chronic, severe lung disease (i.e., COPD, emphysema). The beneficiary was prescribed a PAP and the physician has ordered a home overnight oximetry test that was performed on room air without the beneficiary using their PAP device. The beneficiary desaturated below 88% for more than five total minutes. In this instance, would the home oxygen be covered?

Response: No, home oxygen would not be covered. Beneficiaries with diagnosed but untreated OSA are not in a "chronic, stable state". Therefore, they do not meet the Oxygen LCD Group I or Group II criteria. Only testing with a titration PSG may be used to qualify a beneficiary with OSA for concurrent payment of home oxygen.

7. A beneficiary has a diagnosis of OSA and has been diagnosed with a chronic, severe lung disease (i.e., COPD, emphysema). The beneficiary was prescribed a PAP and the physician has ordered a home overnight oximetry test that was performed on room air with the beneficiary using their PAP device. The beneficiary desaturated below 88% for more than five total minutes. In this instance, would the home oxygen be covered?

Response: No, home oxygen would not be covered. Only testing with a titration PSG may be used to qualify a beneficiary with OSA for concurrent payment of home oxygen.

8. A beneficiary has diagnoses of OSA and chronic, severe lung disease (i.e., COPD, emphysema). The beneficiary has an oximetry testing performed during the day, while at rest. The beneficiary's resting SpO2 is < 88% and the beneficiary's physician has prescribed home oxygen therapy. In this instance, would home oxygen be covered?

Response: Yes, home oxygen would be covered. This beneficiary meets the Oxygen LCD Group I criteria. Oximetry testing while the beneficiary is awake may be used for qualification of home oxygen. While awake OSA does not affect blood oxygen levels.

9. A beneficiary has diagnoses of OSA and chronic, severe lung disease (i.e., COPD, emphysema). The beneficiary has pulse oximetry testing performed during the day, while exercising. The beneficiary's baseline SpO2 is 92% and their SpO2 < 88% during exercise. The beneficiary is tested during exercise while on oxygen and their SpO2 is 92%. The physician prescribes home oxygen therapy for use during activity/exercise. In this instance, would home oxygen be covered?

Response: Yes, home oxygen would be covered. This beneficiary meets the Oxygen LCD Group I criteria. As discussed in Q7, oximetry testing while awake continues to be acceptable for the qualification of home oxygen. OSA does not affect the blood oxygen levels of an awake beneficiary.

10. When oxygen qualification testing is obtained from a titration polysomnogram, is portable oxygen covered?

Response: No, as with overnight oximetry, only stationary oxygen is justified based on titration polysomnography.

11. For a beneficiary now eligible for Medicare who is already on PAP and O2, are both therapies eligible for reimbursement?

Response: Each therapy has separate and independent coverage criteria that must be met in order to be eligible for Medicare reimbursement. Items reimbursed by other payers prior to Medicare eligibility are not a determinant for Medicare program payment. Claims submitted to Medicare for items previously paid outside of Medicare are considered new, initial Medicare claims. All applicable coverage and documentation requirements in effect at the initial Medicare DOS must be met. There are two limited exceptions:

• For PAP:

a. The original testing done to diagnose OSA may be used to qualify for Medicare coverage if the results meet or exceed Medicare AHI/RDI requirements; and,

b. The 90-day compliance period is replaced with an in-person physician visit that documents (1) compliant use of the equipment and (2) benefit from therapy.

• For Home Oxygen:

c. For beneficiaries who start oxygen while enrolled in a Medicare managed care plan, the blood oxygen testing used by the plan for qualification may be used for qualification purposes by fee-for-service Medicare.

Refer to the relevant LCD and related Policy Article for details about coverage and documentation requirements.