1)
Oxygen for
home use is considered medically necessary in the following circumstances:
a)
Diagnosis of
severe lung disease with qualifying lab values:**
i)
Chronic
obstructive pulmonary disease (COPD)
ii)
Diffuse
interstitial lung disease
iii)
Cystic
fibrosis
iv)
Bronchiectasis
v)
Widespread
pulmonary neoplasm
vi)
Pediatric
bronchopulmonary dysplasia (BPD);
b)
Diagnosis of
other hypoxia-related symptoms or findings with qualifying lab values:**
i)
Pulmonary
hypertension
ii)
Recurring
congestive heart failure due to chronic cor-pulmonale
iii)
Erythrocytosis (hematocrit greater than 55%);
c)
Other
diagnoses of hypoxia-related symptoms or findings with qualifying lab values**
that usually resolve with limited or short-term oxygen therapy:
i)
Pneumonia
ii)
Asthma
iii)
Croup
iv)
Bronchitis.
Coverage for
these conditions is for short term use only, considered to less than 1 month
duration.
d)
Other
diagnoses for which short-term use of oxygen has been shown to be beneficial
(unrelated to hypoxia), e.g.:
i)
Cluster
headache
ii)
Infants with
BPD.
iii)
Hemoglobinopathies. Self-administration of adjunctive short-term oxygen therapy
in the outpatient setting has been shown to be beneficial and reduce
hospitalizations in individuals with hemoglobinopathies, such as hemoglobin
sickle cell disease, during vaso-occlusive crisis exacerbated by hypoxia.
2)
Oxygen for
home use is considered experimental and investigational for indications other
than those noted above.
3)
**Qualifying
laboratory values:
a)
Continuous Oxygen:
i)
Resting PaO2
less than or equal to 55 mm Hg or oxygen saturation less than or equal to 88%
OR
ii)
Resting PaO2
of 56-59 mm Hg or oxygen saturation of 89% in the presence of any of the
following
(1)
Dependent
edema suggesting congestive heart failure
(2)
P pulmonale
on the electrocardiogram (P wave greater than 3 mm in standard leads II, III, or
aVF)
(3)
Erythrocythemia (hematocrit greater than 56%) OR
iii)
Resting PaO2
greater than 59 mm Hg or oxygen saturation greater than 89% only with additional
documentation justifying the oxygen prescription and a summary of more
conservative therapy that has failed.
b)
Non-continuous Oxygen:
(oxygen flow rate and number of hours per day must be specified)
i)
During
exercise: PaO2 less than or equal to 55 mm Hg or oxygen saturation
less than or equal to 88% OR
ii)
During sleep:
PaO2 less than or equal to 55 mm Hg or oxygen saturation less than or
equal to 88% with associated complications, such as pulmonary hypertension,
daytime somnolence, and cardiac arrhythmias.
NOTE:
Prior to instituting oxygen therapy during sleep, the presence of sleep apnea
should be ruled out.
c)
NOTE:
All qualification studies must be done while on room air unless medically
contraindicated.
4)
Oxygen
Delivery Systems
a)
The following
delivery systems may be considered medically necessary:
i)
Stationary:
Oxygen concentrators, liquid reservoirs, or large cylinders (usually K or H
size) that are designed for stationary use.
(1)
Considered
medically necessary for members who do not regularly go beyond the limits of a
stationary oxygen delivery system with a 50-ft tubing or those who use oxygen
only during sleep.
ii)
Portable:
Systems that weigh 10 lbs or more and are designed to be transported but not
easily carried by the member, e.g., a steel cylinder attached to wheels
(“stroller”).
(1)
Considered
medically necessary for members who occasionally go beyond the limits of a
stationary oxygen delivery system with 50-ft tubing for less than two hours per
day for most days of the week (minimum 2 hours/week).
iii)
Ambulatory:
Systems that weigh less than 10 lbs when filled with oxygen, are designed to be
carried by the member, and will last for four hours at a flow equivalent to 2
L/min continuous flow; e.g., liquid refillable units and aluminum or fiber
wrapped light-weight cylinders, with or without oxygen conserving devices.
(1)
Considered
medically necessary for members who regularly go beyond the limits of a
stationary oxygen delivery system with a 50-ft tubing for two hours or more per
day and for most days of the week (minimum six hours/week).
iv)
Prescription
based on the activity status of the member, the appropriate oxygen delivery
system will be delivered.
v)
Portable Oxygen Concentrators:
Portable oxygen concentrators and combination stationary/portable oxygen systems
are considered medically necessary as an alternative to ambulatory oxygen
systems for members who meet both of the following criteria:
(1)
Member meets
criteria for ambulatory oxygen systems (see above); and
(2)
Member is
regularly (at least monthly) away from home for durations that exceed the
capacity of ambulatory oxygen systems.
vi)
A second
oxygen tank (spare tank) is considered not medically necessary, except in
instances where the member is dependent on continuous oxygen. A single oxygen
tank may be considered medically necessary for a person who is dependent on an
oxygen concentrator.
vii)
Note:
Electrical generators do not meet the definition of DME because they are not
primarily medical in nature.
5)
Reassessment
a)
Note:
Except as noted in short-term cases (see IC above), reassessment of oxygen needs
through pulse oximetry or arterial blood gas is required and must be performed
by an independent respiratory provider at 12 months after the initiation of
therapy for persons who qualify for oxygen based upon an arterial PO2 at or
below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, or at 3
months after initiation for persons who qualify for oxygen based upon an
arterial PO2 between 56 to 59 mm Hg or an arterial oxygen saturation of 89
percent with dependent edema, P pulmonale, or erythrocythemia. Additional
reassessments may be requested at any time at the discretion of QualChoice.
Reassessments must be done by a participating oxygen-qualifying company that is
in no way connected to the company supplying the oxygen therapy (as per Medicare
guidelines). The member`s primary care and/or treating doctor must be notified
for authorization of all testing and treatment changes, including the
discontinuation of coverage for oxygen therapy.
Codes Used In This BI:
E0424 STATION COMPRS GASOUS O2 SYS RENT;
E0425 STATION COMPRS GAS SYS PURCHASE;
E0430 PRTBLE GASEOUS O2 SYS PURCHASE;
E0431 PRTBLE GASEOUS O2 SYS RENTAL;
E0433 PORTBL LIQ O2 SYS RENT; HOME LIQUIF
E0434 PRTBLE LIQUID O2 SYS RENTAL;
E0435 PRTBLE LIQUID O2 SYS PURCHASE;
E0439 STATION LIQUID O2 SYS RENTAL;
E0440 STATION LIQUID O2 SYS PURCHASE;
E0441 STATIONARY O2 CONT GAS 1 MO SPL=1 U
E0442 STATIONARY 02 CONT LQD 1 MO SPL=1 U
E0443 PORTBL O2 CONTENT GAS 1 MO SPL= 1 U
E0444 PORTBL O2 CONTENT LIQ 1 MO SPL=1 U
E1353 REGULATOR
E1354 O2 ACCESS CART PRTBLE CYL/CONC REPL
E1355 STAND/RACK
E1356 O2 ACCESS BTTRY PACK/CRTRDGE REPL
E1357 O2 ACCESS BATTRY CHARGER REPL EA
E1358 O2 ACCESS DC POWER ADAPTER REPL EA
E1372 IMMERSION EXTERNAL HEATER NEBULIZER
E1390 O2 CONC 85%/>02 CONC PRSC FLW RATE
E1391 02 CONC 2 DEL 85%/>02 CONC FLW RATE
E1392 PORTABLE OXYGEN CONCENTRATOR RENTAL