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 asleepwhich 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; and
- Breathlessness without evidence of hypoxemia; and
- Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; and
- 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 during sleep for indications other than those listed above is considered not medically necessary