Oxygen (ARCHIVED)

Policy ID: E-19-020

Section: Durable Medical Equipment

Effective Date: November 01, 2019

Revised Date: March 01, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been Archived Effective May 06, 2024. Click the Archive tab above for more information.

Policy ID: E-19-019

Section: Durable Medical Equipment

Effective Date: November 01, 2019

Revised Date: November 14, 2022

Revision Effective Date: January 02, 2023

Last Reviewed: November 15, 2023

Archived Date: May 05, 2024

Applies To: Commercial and Medicaid Expansion

Description

Oxygen is administered by devices that provide controlled oxygen concentrations and flow rates. Oxygen therapy should maintain adequate tissue and cell oxygenation while avoiding oxygen toxicity.

Criteria

Oxygen and oxygen supplies may be considered medically necessary for appropriately selected individuals only in cases when oxygen is prescribed by a physician. The prescription must specify:

A diagnosis of the disease requiring use of oxygen; and
Oxygen concentration and flow rate; and
Frequency of use (if an intermittent or leave in oxygen therapy, order must include time limits and specific indications for initiating and terminating therapy); and
Method of delivery; and
Duration of use (if the oxygen is prescribed on an indefinite basis, care must be periodically reviewed to determine whether a medical need continues to exist).

Oxygen therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

A4606

A4608

A4615

A4616

A4617

A4619

A4620

E0424

E0425

E0439

E0440

E0441

E0442

E0447

E0455

E0550

E0555

E0560

E1352

E1353

E1354

E1355

E1356

E1357

E1358

E1390

E1391

E1392

E1399

E1405

E1406

Oxygen therapy may be considered medically necessary for ANY of the following:

Cluster headaches; or
Severe lung disease, defined as either: a resting arterial oxygen partial pressure (PaO2) below 55 mm Hg; or O2 saturation less than 90%; or symptoms associated with oxygen deprivation, (e.g., impairment of cognitive processes, restlessness, or insomnia). Examples of severe lung disease include, but are not limited to:
- Chronic obstructive pulmonary disease (COPD); or
- Pulmonary fibrosis; or
- Cystic fibrosis; or
- Bronchiectasis; or
- Bronchiolitis; or
- Recurring congestive heart failure due to chronic cor pulmonale; or
- Respiratory syncytial virus (RSV); or
- Chronic lung disease complicated by erythrocytosis (hematocrit greater than 56%).

Oxygen therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

E0445

E0580

E0585

E1390

E1392

Supplemental home oxygen therapy may be considered medically necessary during sleep in an individual with ANY of the following conditions:

Unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure, or erythrocytosis and hematocrit is greater than 56%; or
When obstructive sleep apnea (OSA), other nocturnal apnea, or a hypoventilation syndrome has been ruled out and there is documentation of desaturation during sleep to an SaO2 of equal to or less than 88% for at least five (5) minutes while asleep; or
When an individual with documented OSA, other nocturnal apnea, or a hypoventilation syndrome experiences desaturation during sleep to a SaO2 of equal to or less than 88% for at least five (5) minutes while asleep which persists despite use of continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV) devices.

Oxygen therapy is considered not medically necessary for the following conditions:

Angina pectoris in the absence of hypoxemia; or
Breathlessness without evidence of hypoxemia; or
Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or
Terminal illnesses that do not affect the lungs.

Portable oxygen systems may be considered medically necessary only if the individual ambulates on a regular basis.

Supplemental home oxygen therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

E0430

E0431

E0433

E0434

E0435

E0443

E0447

E1390

K0738

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New Policy for ND

Internal Medical Policy Committee 9-21-2020 Annual Review-no changes

Internal Medical Policy Committee 9-21-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 Updating clarifying language.

Internal Medical Policy Committee 11-29-2022 Revision-Effective January 02, 2023

Updated Criteria

Internal Medical Policy Committee 11-15-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-19-2024 Archived - Effective May 06, 2024.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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Medical Policies Quick Search

Oxygen (ARCHIVED)

This policy has been Archived Effective May 06, 2024. Click the Archive tab above for more information.

Description

Criteria

Procedure Codes

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer