mp-317 - mp-317 - Medical Policies
Policy Number: MP-317
Latest Review Date: December 2019
Policy Grade: Effective 05/1/2013: Active Policy but no longer scheduled for regular literature reviews and updates.
New initiation of Oxygen therapy may be considered medically necessary for patients with significant hypoxemia when oxygen is prescribed by a physician and evidenced by any of the following blood gas values:
- A PaO2 ≤ 55 mm Hg or SaO2 ≤ 88%, taken at rest, on room air.
- A PaO2 ≤ 55 mm Hg or SaO2 ≤ 88%, taken during sleep, for a patient who demonstrates a PaO2 ≥ 56 mm Hg or SaO2 ≥ 89% while awake.
- A PaO2 ≤ 55 mm Hg or SaO2 ≤ 88%, taken during exercise, for a patient who demonstrates a PaO2 ≥ 56 mm Hg or SaO2 ≥ 89% during the day while at rest.
- A decrease in PaO2 of more than 10 mm Hg or a decrease in SaO2 of more than 5% during sleep, associated with signs or symptoms of nocturnal hypoxemia (e.g., impaired cognitive process, restlessness, insomnia).
- A PaO2 of 56-59 mm Hg or SaO2 ≤ 89%, in the presence of dependent edema suggesting congestive heart failure, evidence of pulmonary hypertension or cor pulmonale, or erythrocytoses (hematocrit > 56%).
Some of the diseases that may require oxygen therapy include, but are not limited to, the following:
- Chronic obstructive pulmonary disease (COPD)
- Pulmonary fibrosis
- Cystic fibrosis
- Recurring congestive heart failure due to chronic cor pulmonale
- Widespread pulmonary neoplasia
- Pediatric bronchopulmonary dysplasia (BPD)
- Pulmonary hypertension (P wave > 3 mm in standard leads II, III or AVF)
- Chronic lung disease complicated by erythrocytosis (Hematocrit > 56%)
- Persistent, but resolving hypoxemia due to respiratory infection
- Chronic severe angina with hypoxemia.
For the above indications, the initiation of oxygen requires the results of a blood gas study that has been ordered and evaluated by the attending physician. A measurement of arterial oxygen saturation obtained by ear or pulse oximetry, however, is also acceptable when ordered and evaluated by the attending physician and performed under his or her supervision or when performed by a qualified provider or supplier of laboratory services. When the arterial blood gas and the oximetry studies are both used to document the need for home oxygen therapy and the results are conflicting, the arterial blood gas study is the preferred source of documenting medical need. A DME supplier is not considered a qualified provider or supplier of laboratory services for purposes of these coverage criteria. See additional policy guidelines below.
Oxygen therapy may be considered medically necessary for short-term use in some conditions unrelated to hypoxemia, including the following:
- Cluster headache when other treatments have failed. Cluster headache is defined as at least 5 attacks with at least 1 headache per day and the headaches have the following components:
- Patient has severe unilateral orbital, supraorbital, or temporal pain lasting at least 15 minutes; and
- At least one for the following symptoms on the headache side:
- Conjunctival injection; or
- Lacrimation; or
- Nasal congestion; or
- Rhinorrhea; or
- Forehead and facial sweating; or
- Miosis; or
- Ptosis; or
- Eyelid edema.
- Infants with BPD who have variable oxygen needs
These indications do not require blood gas levels to meet medical criteria for coverage.
Oxygen therapy may be considered medically necessary in patients with lung cancer who have dyspnea relieved by oxygen. These patients do not require blood gas levels to meet medical criteria for coverage.
Oxygen therapy is considered not medically necessary for the following conditions:
- Angina pectoris in the absence of hypoxemia
- Breathlessness without evidence of hypoxemia
- Peripheral vascular disease which could result in clinically evident desaturation in one or more extremities
- Terminal illness that does not affect the lungs
- Migraine headaches
1. There must be documentation of an arterial blood gas or arterial oxygen saturation result as ordered and evaluated by the attending physician, within 30 days of certification or recertification.
2. The oxygen therapy must be ordered by a physician and the prescription should include the following:
- A diagnosis of the disease requiring home use of oxygen
- Oxygen concentration and flow rate
- An estimate of the frequency of use (an intermittent or leave in oxygen therapy order must include time limits and specific indications for initiating and terminating therapy
- Method of delivery
- Duration of use (e.g., 2 liters per minute, 10 minutes per hour, 12 hours per day)
- Duration of need (e.g., 6 months to lifetime). If oxygen is prescribed on an indefinite basis, the care must be reviewed every 12 months to determine whether a medical need continues to exist
3. Portable oxygen systems may be considered medically necessary only if the patient ambulates on a regular basis.
4. Routine oxygen supplies include the following (these supplies are only covered as replacement items)
- Portable oxygen systems
- Mask or nasal cannula
- Oxygen gauge
- Oxygen humidifier
- Oxygen tubing
5. The following components of oxygen therapy are considered not medically necessary:
- Oxygen and oxygen supplies in facilities that are expected to supply such items;
- Setup or installation of respiratory support systems;
- Preset regulators used with portable oxygen systems;
- Regulators that permit a flow rate > 8 liters per minute, as these units are not appropriate for home use, except for some patients with terminal illness, such as pulmonary fibrosis, and a life expectancy of six months or less;
- A prescription for oxygen for use as needed (PRN).
6. Delivery charges are considered not medically necessary.
DESCRIPTION OF PROCEDURE OR SERVICE:
Oxygen is administered by inhalation utilizing devices that provide controlled oxygen concentrations and flow rates to the patients. Oxygen therapy should maintain adequate tissue and cell oxygenation while trying to avoid oxygen toxicity. The patient’s condition is monitored to ensure that the patient is receiving the proper mixture of gases, mists and aerosols.
A patient’s oxygen level may be measured in several ways. By drawing a sample of blood from an artery (ABG or arterial blood gas), the oxygen level in the blood, called PaO2, can determine whether or not a patient requires oxygen. Another method is to use a device called a pulse oximeter or saturation meter, which measures how saturated the blood is with oxygen (O2 saturation or “sat” or SaO2). These devices clip onto the finger, toe, or ear, and check the oxygen saturation of the blood by light beams. The SaO2 numbers are not the same as the PaO2, but they yield similar information.
Literature review through December 2019.
Home oxygen therapy, arterial blood gas, arterial oxygen tension (PaO2), arterial oxygen saturation (SaO2), hypoxemia, cluster headache, ABG
APPROVED BY GOVERNING BODIES:
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
Coverage for respiratory therapist services is subject to the member’s specific group benefits.
ITS: Home Policy provisions apply
FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
A4615 Cannula, nasal
A4616 Tubing (oxygen), per foot
A4617 Mouth piece
A4618 Breathing circuits
A4619 Face tent
A4620 Variable concentration mask
A4623 Tracheostomy, inner cannula
E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing
E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor
E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing
E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0441 Stationary oxygen contents, gaseous, 1 month’s supply = 1 unit
E0442 Stationary oxygen contents, liquid, 1 month’s supply = 1 unit
E0443 Portable oxygen contents, gaseous, 1 month’s supply = 1 unit
E0444 Portable oxygen contents, liquid, 1 month’s supply = 1 unit
E0447 Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm) (Effective 01/01/2019)
E0455 Oxygen tent, excluding croup or pediatric tents
E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each
E1357 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each
E1358 Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each
E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each
E1392 Portable oxygen concentrator, rental
E1405 Oxygen and water vapor enriching system with heated delivery
E1406 Oxygen and water vapor enriching system without heated delivery
K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing
S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot
S8121 Oxygen contents, liquid, 1 unit equals 1 pound
- American Association for Respiratory Care (AARC). Clinical Practice Guideline. Oxygen therapy in the home or alternate site health care facility-2007 revision and update. Respiratory Care, August 2007; 52(8): 1063-1068.
- American Association for Respiratory Care (AARC). Clinical Practice Guideline. Selection of an oxygen delivery device for neonatal and pediatric patients: 2002 revision and update. Respiratory Care 2002; 47(6): 707-716.
- American Thoracic Society. Management of stable COPD: Long-term oxygen therapy. 2004, www.thoracic.org/sections/copd.
- Bailey RE. Home oxygen therapy for treatment of patients with chronic obstructive pulmonary disease. American Family Physician 2004; 70(5): 864-865.
- Beck E, et al. Management of cluster headache. American Family Physician 2005; 71(4): 717-724.
- Centers for Medicare and Medicaid Services (CMS). Decision memo for home use of oxygen. March 2006. www.cms.hhs.gov/mcd/.
- Centers for Medicare and Medicaid Service (CMS). NCD for home use of oxygen. October 1993, Publication 100.3, Section 240.2. www.cms.hhs.gov/mcd/.
- Chaouat A, et al. A randomized trial of nocturnal oxygen therapy in chronic obstructive pulmonary disease patients. European Respiratory Journal 1999; 14: 1002.
- Croxton TL, et al. Long-term oxygen treatment in chronic obstructive pulmonary disease: Recommendations for future research: an NHLBI Workshop Report. American Journal Respiratory Critical Care Medicine 2006; 174: 373.
- Doherty DE, et al. Recommendations of the 6th long-term oxygen therapy consensus conference. 2006 Respiratory Care 51, pp. 519.
- Eaton T, et al. Long-term oxygen therapy improves health-related quality of life. Respiratory Medicine 2004; 98: 285.
- Huber G. Oxygen therapy influences episodic cluster headache and related cutaneous brush and cold allodynia. Headache 2009; 49(1):134-6.
- Ingenito EP. Medical therapy for chronic obstructive pulmonary disease in 2007. Semin Thoracic Cardiovascular Surgery 2007; 19(2): 142-150.
- Lau J, et al. Long-term oxygen therapy for severe COPD. Agency for Healthcare Research and Quality (AHRQ). Tufts-New England Medical Center Evidence-Based Practice Center. June 2004.
- Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Report of the Medical Research Council Working Party. Lancet 1981; 1: 681.
- Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: A clinical trial. Annals of Internal medicine 1980; 93: 391.
- Nonoyama ML, et al. Effect of oxygen on health quality of life in patients with chronic obstructive pulmonary disease with transient exertional hypoxemia. American Journal Respiratory Critical Care Medicine 2007; 176: 343.
- Qaseem A, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, November 2007; 147(9): 633-638.
- Ram SF, et al. Ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Review 2002, Vol. 2: CD000238.
- Stewart BN, et al. Long-term results of continuous oxygen therapy at sea level. Chest 1975; 68: 486.
- Tanni SE, et al. Influence of the oxygen delivery system on the quality of life of patients with chronic hypoxemia. Journal Bras Pneumology 2007; 33: 161.
- Wilt TJ, et al. Management of stable chronic obstructive pulmonary disease: A systematic review for a clinical practice guideline. Annals of Internal Medicine, November 2007; 147(9): 639-653.
Medical Policy Group, April 2008 (3)
Medical Policy Administration Committee, June 2008
Available for comment May 21-June 2, 2008
Medical Policy Group, May 2008 (2)
Medical Policy Administration Committee, June 2008
Available for comment June 3-July 17, 2008
Medical Policy Group, July 2008 (2)
Medical Policy Administration Committee, August 2008
Available for comment July 25-September 8, 2008
Medical Policy Group, June 2009 (2)
Medical Policy Administration Committee, June 2009
Available for comment, June 5-July 20, 2009
Medical Policy Group, May 2011 (1) Coding update
Medical Policy Administration Committee, May 2011
Medical Policy Group, November 2012: Deleted Codes K0741 and K0742 effective 12/31/2012
Medical Policy Group, May 2013: Effective 05/1/2013: Active Policy but no longer scheduled for regular peer-literature reviews and updates.
Medical Policy Group, August 2018(6) Removed old coding from prior to 2013 and code E0445, clarified policy statement to include “every 12 months”.
Medical Policy Group, December 2018: 2019 Annual Coding Update. Added HCPC code E0447 to the Current coding section.
Medical Policy Group, December 2019 (6): Updates to Key Points and Key Words (cluster headache, ABG). No change to policy intent.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.