Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/18/1995 Title: Home Oxygen & Oxygen Equipment
Revision Date: 07/01/2016 Document: BI233:00
CPT Code(s): E0424, E0425, E0430, E0431, E0433-E0435, E0439-E0444, E1353-E1358, E1372, E1390-E1392
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Home oxygen and oxygen delivery equipment is covered for use in conditions where oxygen support is needed.

2)    The oxygen delivery systems are covered under the DME benefit.

3)    The oxygen gas is covered under the medical benefit.


Medical Statement

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
 


Limits

1)    Oxygen therapy is not covered for the following:

a)    Patients with angina pectoris unless hypoxia is present and documented.  This condition is generally not the result of a low oxygen level in the blood, and there are other preferred treatments.

b)    Patients with terminal illness not affecting the lungs.

c)     Breathlessness without cor pulmonale or evidence of hypoxemia.  Although intermittent oxygen use is sometimes prescribed to relieve this condition, it is potentially harmful and psychologically addicting.

d)    Severe peripheral disease resulting in clinically evident desaturation in one or more extremities.  There is no evidence that increased PO2 improves the oxygenation of tissues with impaired circulation

e)    PRN usage.


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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