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Coverage criteria policies



Oxygen is covered at the Durable Medical Equipment benefit stated in your member contract when your medical provider has ordered it.

Oxygen is available via 3 methods:

  1. Oxygen concentrator,
  2. Oxygen gas cylinders,
  3. Liquid oxygen system (2 types of units: stationary system & portable system)

Provider and Billing Information:

Units are rented up to a 36 month capped rate. Vendor retains ownership. A new rent cap period begins when the equipment reaches the Reasonable Useful Lifetime period.

The Reasonable Useful Lifetime for stationary or portable oxygen equipment begins when the oxygen equipment is first delivered to the member and continues until the point at which the stationary or portable oxygen equipment has been used by the member on a continuous basis for 5 years. Computation of the Reasonable Useful Lifetime is not based on the age of the equipment.

If oxygen equipment that is not functioning properly has to be replaced prior to the end of the Reasonable Useful Lifetime period, this does not result in the start of a new reasonable useful lifetime period or a new 36 month payment period.

When provider bills the first month of a new oxygen equipment episode the rental modifier (RR) needs to be billed. The replacement modifier (RA) should be billed as a secondary modifier since its replacement equipment.  Include a narrative description to also indicate that it is replacement equipment as member has had the equipment for the Reasonable Useful Lifetime Period.

All accessories are included in the allowance for rented oxygen equipment. Accessories, including but not limited to, transtracheal catheters (A4608), cannulas (A4615), tubing (A4616), mouthpieces (A4617), face tent (A4619), masks (A4620, A7525), oxygen conserving devices (A9900), oxygen tent (E0455), humidifiers (E0555), nebulizer for humidification (E0580), regulators (E1353), and stand/rack (E1355) are included in the allowance for rented oxygen equipment. The supplier must provide any accessory ordered by the medical provider.

Continuous Use of Oxygen and Oxygen Equipment

A period of continuous use allows for temporary interruptions in the use of the equipment. For breaks in need (beneficiary no longer needs or uses the equipment) of less than 90 days plus the days remaining in the last paid rental month, the period of continuous use does not start over and so the count of continuous months picks up where it left off before the break.

If, however, there is a break in need more than 90 days plus the days remaining in the last paid rental month, and the need for the equipment resumes at a later date, a new period of continuous use, a new 36-month payment period, and a new Reasonable Useful Lifetime Period would begin provided that:

  1. The supplier submits new medical necessity documentation and a narrative explaining why there was a break in need for the equipment; and
  2. The contractor determines that there was a break in need of greater than 90 days plus the days remaining in the last paid rental month followed by a resumption in medical necessity for the oxygen equipment.

Maintenance and Servicing Fee:

Maintenance and servicing fee is covered and the fee covers all maintenance and servicing through the following 6 months after oxygen equipment has reached it rental cap period that are needed in order to keep the oxygen equipment in good working order.

A single maintenance and servicing fee payment is made per beneficiary regardless of:

  • The number of pieces of equipment serviced (stationary concentrator, portable concentrator, and/or transfilling equipment);
  • When the maintenance and servicing is performed during each 6-month period; or
  • How often the equipment must be maintained and serviced.

The provider must make at least one maintenance/servicing visit to inspect the equipment, and provide any maintenance and servicing needed at the time of the visit during the first month of each 6-month period.

Further, the maintenance and servicing payments discontinue when a new rent cap period begins.

Indications that are not covered

Emergency oxygen systems are not covered, as they are not medically necessary.

Oxygen, Hyperbaric Not addressed in this guideline. See policies: Topical Hyperbaric Oxygen for Wound Healing and Hyperbaric Oxygen Therapy


Travel Coverage –

  1. If a member travels out of their vendor’s usual service area, the member is responsible to work with their vendor to arrange for oxygen during their travel. HealthPartners will only pay one vendor during any one rental month.
  2. Some members may have a travel benefit and the oxygen coverage during travel / vacation may be subjected to those benefit limits.

Oxygen Refills
The refill of liquid oxygen contents into a stationary liquid oxygen system is done via truck refill by the vendor.

The oxygen gas cylinders (green tanks) are replaced by vendor when empty.

Oxygen Carrier
An oxygen carrier is a device attached to a wheelchair and is used to carry an oxygen cylinder, or a stand / rack that holds a cylinder moved by the user, or a shoulder bag to hold portable tank. These are included in the rented system.

Oxygen Humidifier
A bottle filled with water which attaches to the oxygen system. Humidity may be necessary to increase moisture into the user’s airway. These are included in the rental system.

Oxygen Regulator
Oxygen regulators attach to the oxygen gas cylinder (green tank). This flow gauge allows user to adjust the flow to deliver a prescribed amount of oxygen. These are included in the rented system.

Oxygen Concentrator
A stationary or portable device that extracts oxygen from room air, and delivers oxygen at high concentration to the user via tubing, face mask, or nasal cannula. A backup system, usually an oxygen gas cylinder accompanies a concentrator in case of power failure, and is included in the rented system.

Oxygen, gas cylinder
A green tank that is available in various sizes and stores oxygen in a gaseous state under high pressure. The smaller tanks are portable and are for use when away from home or as a backup system in case of power failure. Backup oxygen system is included in the rented system. When tanks are empty the vendor must replace them.

Oxygen system, Liquid
A liquid oxygen system is a sophisticated thermos-like container that stores oxygen at 297 degrees. It consists of a large main unit that is stationary, and a separate smaller portable unit. The portable unit, used when away from home, can be refilled by the user from the large main stationary unit.

Oxygen, portable
Portable oxygen provides the user with an oxygen supply when away from home. It may be an oxygen gas cylinder with attached regulator flow gauge, a portable concentrator, a small Liquid oxygen unit or HELIOS. It includes a regulator, tubing, mask or cannula.

Oxygen Conserving Device (A9900)
The oxygen conserving device or oxygen regulator (may be called Helios) is a device which releases oxygen only during inhalation. This unit replaces the traditional oxygen regulator / flowmeter, which delivers a continuous flow of oxygen.

Oxygen for use on Airplanes
Members must work with the airline to determine what type of portable oxygen is allowed. They also need to coordinate with their oxygen DME vendor to obtain the proper equipment while traveling. Upgrades or duplicate oxygen equipment are not covered per your DME benefit.

Vendor - Full Line

  • For in network benefits to apply, items must be received from a contracted vendor.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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