Okla. Admin. Code § 317:30-5-211.11

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-211.11 - Oxygen and oxygen equipment

(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.

Okla. Admin. Code § 317:30-5-211.11

Added at 24 Ok Reg 2890, eff 7-1-07 (emergency); Added at 25 Ok Reg 1161, eff 5-25-08

Amended by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015

Amended by Oklahoma Register, Volume 40, Issue 24, September 1, 2023, eff. 9/11/2023