`E0433` Portable liquid oxygen sys

Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction

Medicare pricing for E0433

DMEPOS fee schedule, July 2026 (DME26-C)

RR (rental), oxygen and oxygen equipment (OX): non-rural $46.28 to $50.81 in the contiguous states; $51.63 in AK, HI, PR and VI; rural $51.63
RR-QB, oxygen and oxygen equipment (OX): non-rural $48.20 to $50.81 in the contiguous states; $88.58 in AK, HI, PR and VI; rural $88.58
RR-QF, oxygen and oxygen equipment (OX): non-rural $48.20 to $50.81 in the contiguous states; $88.58 in AK, HI, PR and VI; rural $88.58

Payer policies and prior authorization for E0433

4 of 4 payer prior-auth lists that name E0433 require prior authorization or set conditions: Humana, Medicare, Molina Healthcare of Mississippi, Rocky Mountain Health Plans.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Medicare	DMEPOS Master List (items potentially subject to PA)	All	prior auth under conditions	On the Master List; PA only if CMS selects it for the Required List	Jul 30, 2026	Master List of DMEPOS Items Potentially Subject to Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Molina Healthcare of Mississippi	Medicaid	MS	prior auth required	State exception	Jan 1, 2025	Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025

Payer coverage policies that name E0433

E0433 appears in 6 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross & Blue Shield of Rhode Island, Centene.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Oxygen (0002)	covered if criteria are met	Mar 10, 2026	payer document
Aetna	Pulse Oximetry and Capnography for Home Use (0339)	listed, no stance (range E0424-E0444)	May 21, 2026	payer document
Anthem	Home Oxygen Therapy (CG-DME-18)	covered if criteria are met	Aug 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Oxygen (L.1.01.403)	covered if criteria are met		payer document
Blue Cross & Blue Shield of Rhode Island	Multifunction Home Ventilators PAYMENT POLICY \| 2	listed, no stance	May 15, 2024	payer document
Centene	Outpatient Oxygen Use (CP.MP.190)	covered if criteria are met	Nov 1, 2025	payer document

Medicaid fee-for-service

Prior authorization required or conditional in IN, KY, LA, MS, ND, OH, VA.

AZ: $47.17 (dme_rentals), effective Oct 1, 2026
CO: $39.43 (chp_plus, non-facility), effective Jul 1, 2026
IN: $38.30 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2025
KS: $39.62 (default), effective Jul 1, 2026
KY: $46.53 (dme), effective Jan 1, 2026
LA: $34.80 (dme), effective Jul 1, 2012
MS: $41.30 (comprehensive), effective Jul 1, 2026
ND: $43.29 (dme), effective Aug 1, 2026
OH: $19.34 (dme), effective Jan 1, 2026
TX: $41.30 (dmepos_tos_9_e_j_l_and_r, Home Health Dme), effective Apr 1, 2017
VA: $1.89 (medical, High Intensity), effective Jul 1, 2024
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

E0433 Portable liquid oxygen sys