Does K0738 require prior authorization?

Yes, K0738 requires prior authorization (high confidence). Code explicitly requires prior authorization.

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`K0738`, Portable gaseous oxygen system, rental; home compressor used to fill portable

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD), the supplier must receive a signed WOPD before delivery or the claim will be denied.
Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor on request; claims without appropriate POD will be denied.
Qualifying blood gas studies must comply with MAC policy standards and be performed by a provider qualified to bill Medicare (Part A provider, laboratory, IDTF, or treating practitioner); suppliers may not perform or pay for qualifying blood gas testing.

Exercise-based qualification requires documentation in the medical record of three oximetry studies performed within the same testing session: (1) rest without oxygen, (2) during exercise without oxygen, and (3) during exercise with oxygen applied; only test #2 is used for qualification and all three results must be available upon request.

Overnight home oximetry devices must be tamper-proof and capable of downloading data that documents duration of desaturation; baseline saturation is defined as the mean saturation during the recorded test and the home overnight test must record at least 2 hours to meet Group I criterion 3.

For home overnight oximetry performed under IDTF direction, the treating practitioner must order the test, the IDTF must provide written instructions and receive/transmit results to the treating practitioner, and the DME supplier may not access or manipulate results except to download and transmit to the IDTF under specified conditions.

Key Coverage Criteria

Initial coverage for home oxygen and oxygen equipment is reasonable and necessary only if the treating practitioner ordered and evaluated a qualifying blood gas study performed at the time of need, the study meets the coverage criteria, the study was performed by a treating practitioner or qualified provider/laboratory, and provision of home oxygen is expected to improve the beneficiary’s condition.
Group I: Coverage if arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% at rest (awake) breathing room air.
Group I (sleep-only): Coverage if arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% during sleep for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or saturation ≥ 89% while awake, with oxygen reasonable and necessary only during sleep.
Group I (sleep desaturation from baseline): Coverage if during sleep PO2 decreases >10 mm Hg or oxygen saturation decreases >5% from baseline and the decrease is associated with hypoxemia symptoms (e.g., cognitive impairment, nocturnal restlessness), with oxygen reasonable and necessary only during sleep.
Group I (exercise): Coverage if arterial PO2 ≤ 55 mm Hg or saturation ≤ 88% during exercise for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or saturation ≥ 89% at rest while awake; in this case portable oxygen is reasonable and necessary only while awake and during exercise.
Group II: Coverage if arterial PO2 is 56–59 mm Hg or arterial saturation is 89% and the beneficiary has at least one of: dependent edema suggesting congestive heart failure, pulmonary hypertension or cor pulmonale documented by pulmonary artery pressure measurement, gated blood pool scan, echocardiogram, or P pulmonale on EKG, or erythrocythemia with hematocrit > 56%.

4 Active Policies

ANTHEM-CG-DME-18, Home Oxygen Therapy

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33797, Oxygen and Oxygen Equipment

AMBETTER-CP.MP.190, Outpatient Oxygen Use

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K0738, Portable gaseous oxygen system, rental; home compressor used to fill portable