Sorry. That first sentence should read

....at rest to qualify for supplemental oxygen.

:o)

80 is the limit here, if it goes below you should still be oxygen, even 80 is causing damage to your hart and kidneys. i cant imagine them taking you off it , i might be wrong . but im sure im right. dont stop taking it unless you doctor says so.
blessings

Never type a question right before going to bed!

My concern is the criteria for Medicare before they will cover oxygen therapy.

Resperitory therapist said PO2 should be in the 75-100 range to be off oxygen completely, but from what I have read Medicare says P02 of 55-58 on an ABG.

Zenna, are you talking about oxygen saturation on a pulse ox? I have been told below 85 is dangerous.

Thanks!

Joni, I could not find the specific answer to your question...but here is links to Social Security and Medicare. Maybe the answer is here in some obscure place. Hope this helps. JoAnn
http://www.ssa.gov/

http://www.ssa.gov/disability/professionals/bluebook/3.00-Respiratory-Adult.htm#3.02%20Chronic%20pulmonary%20insufficiency

Thanks, JoAnn...

I researched the Medicare sites where I found the PO2 of 58 or below. It is confusing. According to SSA I am considered disabled, but to medicare I don't need oxygen? So confusing!

Sassy....I found this today. It might be helpful, not only to me but others as well. Following the link at the bottom of the article will give more information. I realize it is a "long read" but worth it.


Long-term supplemental oxygen therapy

Brian L Tiep, MD
Rick Carter, PhD, MS, MBA


UpToDate performs a continuous review of over 330 journals and other resources. Updates are added as important new information is published. The literature review for version 13.1 is current through December 2004; this topic was last changed on January 16, 2004. The next version of UpToDate (13.2) will be released in June 2005.

INTRODUCTION Oxygen has been demonstrated to increase survival and improve the quality of life in patients with chronic obstructive pulmonary disease (COPD) (show figure 1 and show figure 2) [1-3]. In the United States, for example, there are currently more than 600,000 patients receiving long-term oxygen therapy (LTOT), most of whom are Medicare recipients with COPD [4].

FINANCIAL ISSUES Although most physicians and health care professionals consider oxygen to be an important drug for the treatment of hypoxemia, the Center for Medicare and Medicaid Services (CMS; formerly called the Health Care Financing Administration, or HCFA) does not pay for outpatient medications for Medicare recipients. However, CMS classifies oxygen and oxygen delivery equipment as durable medical equipment (DME); this definition allows oxygen to be reimbursed as a form of "medical equipment." As a result, a specific Certificate of Medical Necessity (CMN) called the HCFA484 must be completed by the physician in order for oxygen therapy to be reimbursed at a level of 80 percent of the Medicare allowable charge. The patient or supplemental insurance is responsible for the remaining 20 percent of the cost.

The requirements for medical necessity established by CMS are also utilized by most third party payers. These requirements are based primarily on the parameters for entry into the multicenter Nocturnal Oxygen Therapy Trial (NOTT) sponsored by the National Institutes of Health [1]. Indications and guidelines for therapy have been further refined by five national consensus conferences on LTOT [5-9]. These guidelines apply not only to hypoxemic patients with COPD, but also to patients whose hypoxemia is due to other disorders, such as chronic interstitial lung disease, chest wall disease, and cardiac disease [10].

Within these guidelines, it is the physician's responsibility to be involved in selection of appropriate equipment and provision of an individualized prescription that must be transmitted to the DME provider (show figure 3). The prescription must contain several required elements including liter oxygen flow and any changes that may be required for sleep, exercise or other condition, duration of need, and/or the issuance of portable oxygen devices. The physician is now instructed not to sign the CMN form (HCFA-484) unless the provider has correctly restated the prescription in Section C (show figure 4A-4B). Periodically, the physician will need to recertify the patient for supplemental oxygen and this recertification must be completed within a specified period of time to ensure that oxygen is provided without interruption.

INDICATIONS Current indications for continuous long-term oxygen therapy are (show table 1):

Arterial PO2 (PaO2) less than or equal to 55 mmHg or an arterial oxygen saturation (SaO2) less than or equal to 88 percent.

PaO2 between 56 to 59 mmHg or an SaO2 of 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit above 55 percent).


Additional Medicare indications for the use of oxygen during sleep or exercise include the following:

Oxygen may be prescribed during sleep if the PaO2 is 55 mmHg or less, the SaO2 is 88 percent or less, or there is a fall in PaO2 of more than 10 mmHg or a fall in SaO2 of more than five percent with signs or symptoms of hypoxemia. The latter indication is defined by CMS as "impaired cognitive process, restlessness, or insomnia."

Oxygen may be prescribed during exercise if there is a reduction in PaO2 to 55 mmHg or less or in SaO2 to 88 percent or less. One of the most important forms of exercise for patients with COPD is walking to perform the activities of daily living.


Documentation of hypoxemia during sleep or exercise is not justification for continuous oxygen therapy if hypoxemia is not present when the patient is awake and at rest. Furthermore, LTOT has not been documented to be effective in patients with milder degrees of hypoxemia. As an example, one study randomized 135 patients with COPD and a PaO2 of 56 to 65 mmHg to either LTOT or standard therapy [11]. No significant differences in survival were noted at one, two, or three years.

REQUIREMENTS In addition to the PaO2 or SaO2 as indications for LTOT, there are specific requirements that must be fulfilled in order for oxygen to be reimbursed by CMS:

Arterial blood gas analysis or measurement of SaO2 to document the need for outpatient oxygen therapy must be performed by a Medicare qualified laboratory. The intent of this requirement is to prevent the oxygen provider from also being responsible for certifying the medical necessity, since this could represent a conflict of interest.

If oxygen is prescribed at the time of hospital discharge, the arterial blood gas or saturation measurement must be obtained within 2 days of discharge.

Medical management should be optimum when LTOT is prescribed. Shortterm oxygen therapy (STOT) may be necessary for some patients with COPD following hospitalization for exacerbation or during periods of acute illness. Lifetime continuous oxygen therapy should be prescribed only when there is evidence of hypoxemia in a clinically stable patient who is receiving appropriate medical management. It is recommended that the arterial blood gas measurement be repeated in one to three months following an acute illness to determine the need for continuous LTOT [7].

The physician or a member of his or her staff must complete the Certification of Medical Necessity (CMN) Form (HCFA484) (show figure 4A-4B; this can be printed for personal use) and only the physician can sign the form. This requirement is intended to assure the physician's involvement in the prescribing and administration of LTOT.

If the PaO2 is 56 to 59 mmHg or the SaO2 is 89 percent, the blood gas measurement must be repeated in 60 to 90 days in order for oxygen to be continued beyond the initial three months of therapy. This requirement represents a Congressional misunderstanding of the recommendation of the oxygen consensus conference that arterial blood gases should be repeated in one to three months whenever therapy is begun in a clinically unstable patient where the medical management may not be optimal [7].

All patients receiving LTOT must be recertified in 12 months, but retesting of arterial blood gases or oxyhemoglobin saturation is not necessary.

For patients receiving longterm (lifetime) oxygen therapy, renewal of the CMN after the first year is required only when there is a change in the prescription for oxygen. This represents a welcome change in CMS regulations, which previously required yearly recertification with completion of Form HCFA484 annually. If the oxygen supplier changes, a renewal may also be requested.

Portable oxygen is allowed if the Medicare patient is mobile in the home and regularly goes beyond the limits of a stationary oxygen delivery system with 50 feet of tubing. The CMS does not consider travel outside of the home in making this determination and also does not recognize a distinction between portable and ambulatory oxygen. The distinction made by the Pulmonary Medicine community is that ambulatory oxygen delivery systems should weigh less than 10 lbs (4.5 kg) and be easily carried by the patient [8]. These units should be provided for patients who are highly mobile and active. Portable units, such as a steel cylinder on a two-wheeled stroller, cannot be carried by the patient and are difficult to maneuver on stairs and on public or private vehicles of transportation. Portable units should be prescribed for patients who are less mobile and who leave the home only occasionally.


PRESCRIPTION The requirement for the physician to sign the CMN was recommended by the Office of the Inspector General of the United States after a fivestate survey indicated that the physician's knowledge of home oxygen therapy and involvement in writing the prescription were often inadequate [12]. In many cases, the home oxygen supplier was determining the need for therapy and also supplying the equipment without adequate physician input.

Oxygen is reimbursed on a prospective payment basis by CMS, and there is no Medicare requirement concerning the type of equipment being provided by the home oxygen supplier. CMS considers all oxygen delivery systems to be equal and "modality neutral." For patients who require portable systems, there is a small additional reimbursement for a "portable add on" device.

Responsibilities of the physician It is extremely important that the physician be actively involved in this process and prescribe the type of equipment that is most appropriate for each patient's needs (show table 2). The CMN no longer serves as the physician's prescription; therefore, a separate oral or written prescription must be provided to the home oxygen supplier when oxygen is ordered and prior to completion of form HCFA-484 (show figure 3).

The physician should also know the DME providers in the area and encourage the use of those providers who are willing and able to provide the best service and to fill the prescription appropriately. For highly active and mobile patients, the physician should order ambulatory liquid oxygen or lightweight, aluminum or fiberwrapped ambulatory cylinders, both of which may be combined with an oxygen conserving device to substantially increase the functional time and reduce the size and weight of the unit that the patient carries. The DME supplier may not provide patients with the best available technology unless the physician has the knowledge and ability to prescribe it. (See "Oxygen conserving devices").

In addition to determining the medical necessity for home oxygen therapy in patients with COPD, the physician, with the aid of the DME provider, should monitor the use of the oxygen by the patient and the environment in which the oxygen is being used. Patients who continue to smoke while using oxygen represent a hazard to themselves, their families, and other occupants of buildings where they live. Oxygen should not be continued if the patient is unwilling to use it, and advanced ambulatory equipment should not be supplied if the patient is unwilling or unable to be physically active.

Prescription recommendations Arterial blood gas measurements, rather than the measurement of arterial oxygen saturation alone, should be the standard to document the need for LTOT [7]. No patient should be subjected to a lifetime of continuous oxygen therapy based on the imprecise measurement of SaO2 by an oximeter. Thus, every patient with COPD should have baseline measurements that include the level of PaCO2 and pH as well as PaO2. The arterial blood gas measurements also provide an indication of the correlation of SaO2 with PaO2. In addition, the appropriate oxygen flow rate should be determined for each patient as well as an assessment of exercise desaturation, sleep desaturation, and the potential usefulness of transtracheal oxygen therapy.

The flow of oxygen needed to correct hypoxemia should be determined by measurement of PaO2 or SaO2 when LTOT is initiated (show table 3). The precise PaO2 or SaO2 that optimally improves survival and quality of life is not known. One of the early studies that demonstrated increased survival in patients with COPD who received LTOT raised the mean PaO2 during therapy to 71.3 mmHg [13]. In the NOTT study the investigators attempted to maintain the PaO2 between 60 and 80 mmHg [1]. A PaO2 of 60 to 65 mmHg or an SaO2 of 90 to 92 percent is generally considered to be acceptable. This represents clinically "adequate" correction of hypoxemia for most patients and is unlikely to cause significant CO2 retention. (See "Use of oxygen in patients with hypercapnia").

Approximately 20 to 30 percent of patients with COPD who qualify for LTOT because of hypoxemia at rest show additional desaturation during usual activities of daily living, such as walking. As a result, higher oxygen flows may be necessary during these activities. It is therefore important to determine the exercise oxygen prescription while the patient is walking and to include this information in the oxygen prescription. The difference in oxygen flow necessary to correct hypoxemia at rest and during exercise may be magnified when some of the oxygen conserving devices are being used, especially those that utilize an oxygen pulsing device [14].

Physicians should also determine if higher flows of oxygen are necessary to prevent nocturnal oxygen desaturation. The overall importance of nocturnal desaturation is still unclear, since some persons who have no identifiable disease may demonstrate oxyhemoglobin desaturation during sleep. For example, 30 percent of patients with COPD without daytime hypoxemia have been found to experience desaturation during sleep at night [15,16].


Nocturnal use of oxygen is indicated in two groups of patients:

In those patients who qualify for LTOT because of hypoxemia while awake, it is desirable to adjust the flow rate of oxygen, if necessary, to prevent hypoxemia during sleep. In the NOTT study, for example, oxygen flow was routinely increased by one L/min during sleep [1].

In those patients with COPD who have cor pulmonale, right heart failure, or erythrocytosis without evidence of hypoxemia while awake, any period of prolonged desaturation during sleep may be detrimental. Thus, nocturnal monitoring of hypoxemic events and titration of supplemental oxygen is recommended.


Transtracheal oxygen administration Transtracheal oxygen appears to impart significant advantages over nasal oxygen delivery by assuring oxygenation and perhaps reducing the work of breathing [17]. Although transtracheal oxygen therapy is a more invasive alternative, patient acceptance has been exceptionally good and compliance with therapy is substantially enhanced [18]. This is a technology that is currently being underutilized, but it does require organization and commitment by the physician and his or her staff. (See "Transtracheal oxygen therapy").

Oxygen adjunctive to exercise training Hypoxemic patients are prescribed oxygen in order to prevent exertional desaturation as described above. However, a recent double blind study performed on COPD patients, who were not hypoxemic at rest, demonstrated that oxygen during exercise enabled patients to tolerate higher training intensity and increased exercise tolerance [19]. The exact role of oxygen as a rehabilitative adjunct remains to be delineated.


http://www.intmed.mcw.edu/ClinicConf/UpToDate%AE%20'Long-term%20supplemental%20oxygen%20therapy'.htm

Hi jaznjams: If you can not qualify with Medicare for oxygen at rest; try a sleep
study. I was on oxygen 24/7; then got above Medicare's 88%; so they cut offf payment. I paid for my own awhile, but it was way too expensive. My Pulmonary Doc sent me for a sleep study. When I lay down or go to sleep my sats drop way off; qualifying me for nighttime oxygen with Medicare. Just a thought!

hi ms. iris...

good thought! i also have sleep apnea, which is why i wear oxygen at night...was supposed to get a cpap, but somehow that has never
happened.

my stats also drop way off then...low 80's pulse ox at times.

The idea of being without it altogether is like being told I can no longer have a rescue inhaler....panics me.

wow i cant beleave you have to go through so much worry , i was talking oxymeter , but also here if your worry about anything they give it to you so you dont worry, our services do have its flaws like if your age over 65 and you have an assabation (attack)you have had it as the prognosis is so bad thay turn you away from hospital , i read about it on sceince daily. but oxygen is on tap. i am in the uk. have you thought if you cant get it of a portable oxygen , iv read about them and you never need tanks again. just a thought.

i too have sleep apnea have had my o2 for 4 years.2.5 of those cause of sleep apnea also any type of physical exercise and it starts dropping.I have had to go through the yearly assessment but I always get qualified.the veteran hospital is not as difficult as medicare i have found.If they did take it I know what neighbors are on it in an emergency and I do the same for them.gotta watch out for each other.I would be afraid with out mine to.Its a scary thought.that was good info sassyme,thanks