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Oxygen

Section: Durable Medical Equipment
Effective Date: November 01, 2019
Revised Date: October 05, 2019
Last Reviewed: September 26, 2019

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).

Procedure Codes

A4606A4608A4615A4616A4617A4619A4620
E0424E0425E0439E0440E0441E0442E0447
E0455E0550E0555E0560E1352E1353E1354
E1355E1356E1357E1358E1390E1391E1392
E1399E1405E1406

Oxygen therapy may be considered medically necessary for:

  • 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); and
    • Pulmonary fibrosis; and
    • Cystic fibrosis; and
    • Bronchiectasis; and
    • Recurring congestive heart failure due to chronic cor pulmonale; and
    • Chronic lung disease complicated by erythrocytosis (hematocrit greater than 56%).

Oxygen therapy for indications other than those listed above (and during sleep as listed below) is considered not medically necessary.

Procedure Codes

E0445E0580E0585E1390E1392

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; 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.

Procedure Codes

E0430E0431E0433E0434E0435E0443
E0447E1390K0738

Oxygen saturations cannot be performed by a Durable Medical Equipment company or a respiratory equipment provider.

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