Current through Vol. 42, No. 1, September 16, 2024
(a)
Medical
necessity. Oxygen and oxygen supplies are covered when medically
necessary. Medical necessity is determined from results of arterial blood gas
analysis (ABG) or pulse oximetry (SaO2) tests. ABG data are not required for
children, but may be used if otherwise available. The test results to document
Medical Necessity must be within thirty (30) days of the date of the qualified
medical practitioner's order. Prior authorization is required after the initial
three (3) months of billing whether qualifying tests were done at rest, during
sleep, or during exercise. Appropriate documentation of ABG or SaO2 data from
the member's chart should be attached to the prior authorization request (PAR).
(1) The ABG or oximetry test used to
determine medical necessity must be performed by a medical professional
qualified to conduct such testing. The test may not be performed or paid for by
a DMEPOS supplier, or a related corporation. A referring qualified medical
practitioner may perform the test in his/her office as part of routine member
care.
(2) In addition to ABG data,
the following three (3) tests are acceptable for determining medical necessity
for oxygen prescription:
(A) At rest and
awake "spot oximetry."
(B) During
sleep:
(i) Overnight Sleep Oximetry done
inpatient or at home.
(ii)
Polysomnogram, which may be used only if medically necessary for concurrent
evaluation of another condition while in a chronic stable
state.
(C) During
exercise with all three (3) of the following performed in the same testing
session.
(i) At rest, off oxygen showing a
non-qualifying result.
(ii) During
exercise, off oxygen showing a qualifying event.
(iii) During exercise, on oxygen showing
improvement over test (C) ii above.
(3) Certification criteria:
(A) All qualifying testing must meet the
following criteria:
(B) Adults.
Initial requests for oxygen must include ABG or resting oximetry results. At
rest and on room air, the arterial blood saturation (SaO2) cannot exceed
eighty-nine percent (89%) or the pO2 cannot exceed 59mm Hg.
(C) Children. Members twenty (20) years of
age or less must meet the following requirements:
(i) birth through three (3) years, SaO2 equal
to or less than ninety-four percent (94%); or
(ii) ages four (4) and above, SaO2 level
equal to or less than ninety percent (90%).
(iii) Requests from the qualified medical
practitioner for oxygen for children who do not meet these requirements should
include documentation of the medical necessity based on the child's clinical
condition. These requests are considered on a case-by-case
basis.
(b)
Guidelines. For full
guidelines, please refer to www.okhca.org/mau.
Added at 24 Ok Reg
2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff
5-25-08
