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April 2015

Reminder: Blue Cross’ DME Home Oxygen Equipment and Related Supplies Medical Policy

We’d like to remind you that, effective Jan. 1, 2015, Blue Cross Blue Shield of Michigan established a Home Oxygen Equipment and Related Medical Supplies Medical Policy that aligns closely with Medicare’s criteria, with the exception of the 36-month rental limit. Here’s what you need to know:

Equipment:
E0424, E0425, E0430, E0431, E0433-E0435, E0439-E0446, E1390-E1392, E1405, E1406, K0738

Accessories:
A4575, A4606, A4608, A4615-A4617, A4619, A4620, A7525, A9900, E0455, E0555, E0580, E1353-E1358

Basic Benefit Policy
Home oxygen equipment and related supplies are established as clinically safe and effective procedures. They may be considered useful for therapeutic options when indicated, effective Jan. 1, 2015.

BCBSM will align our Home Oxygen Equipment and Related Supplies Medical Policy with Medicare's criteria, with the exception of the 36-month rental limit. We will continue to review this policy and will update you with any changes.

For more detailed descriptions of the Blue Cross policies for these procedures, check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

  • Log in to web-DENIS.
  • Click on BCBSM Provider Publications & Resources.
  • Click on Benefit Policy for a Code.
  • Click on Topic.
  • Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
  • Enter the procedure code.
  • Click on Finish.
  • Click on Search.

Failure to follow these policies may result in monetary recoveries on retrospective audits.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.