Coverage Criteria for Healthcare Providers

Criteria for Coverage

Need a prescription, chart notes, and oxygen saturations.


  • Diagnosis: Must include a diagnosis (e.g. Hypoxemia – R09.02)
  • Length of Need: Indicate the duration for which the supplemental oxygen is required
  • Liter Flow: Include the liter flow in LPM or L/min.
  • Date: Include the date of the prescription.
  • Signature: Must be signed by the prescribing healthcare provider.

Note: A template from Kohll’s Rx may be faxed over to ensure all necessary information is provided in the prescription.


Must be less than a year old.
Must mention the patient’s need for supplemental oxygen and how they will benefit from oxygen therapy.


  • Must be within the last 30 days.
    If the patient is leaving the hospital, the oxygen saturations must be within two days of discharge.
  • Must be 88% or lower – if oxygen saturations were only done while the patient was sleeping, they qualify for night use only.

These criteria help ensure that the patient meets the necessary medical requirements for the prescription and use of supplemental oxygen, and they also provide a basis for insurance coverage. It’s important for healthcare providers to adhere to these criteria to facilitate the approval process for oxygen therapy.