Clinical UM Guideline

 

Subject: Home Oxygen Therapy
Guideline #:  CG-DME-18 Publish Date:    10/17/2018
Status: Revised Last Review Date:    09/13/2018

Description

This document addresses the clinical indications for use of home oxygen therapy.

Clinical Indications

Medically Necessary:

  1. Short term supplemental home oxygen therapy is medically necessary for treatment of hypoxemia-related symptoms with qualifying laboratory values (see Note below) associated with acute conditions including, but not limited to any of the following:
    1. Bronchiolitis; or
    2. Chronic obstructive pulmonary disease exacerbation; or
    3. Pneumonia.
  2. Long term supplemental home oxygen therapy is medically necessary for treatment of hypoxemia-related symptoms with qualifying laboratory values (see Note below) from chronic lung conditions including, but not limited to any of the following:
    1. Bronchiectasis; or
    2. Chronic lung disease; or
    3. Chronic obstructive pulmonary disease; or
    4. Cystic fibrosis; or
    5. Diffuse interstitial lung disease; or
    6. Pulmonary hypertension; or
    7. Pulmonary neoplasm (primary or metastatic); or
    8. Recurring congestive heart failure due to chronic cor pulmonale.
  3. Intermittent home oxygen therapy is considered medically necessary for the treatment of cluster headaches.
  4. Supplemental home oxygen therapy is considered medically necessary during exercise when there is documentation of both of the following:
    1. Desaturation to an arterial oxygen saturation (SaO2) of equal to or less than 88% during exercise; and
    2. Improvement in hypoxemia and dyspnea or exercise capacity during exercise while using supplemental oxygen.
  5. Supplemental home oxygen therapy is considered medically necessary during sleep in an individual with any of the following conditions:
    1. Unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure, or erythrocytosis and hematocrit is greater than 56%; or
    2. When obstructive sleep apnea, 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 greater than 30% of the night; or
    3. When an individual with documented obstructive sleep apnea, other nocturnal apnea, or a hypoventilation syndrome experiences desaturation during sleep to an SaO2 of equal to or less than 88% for greater than 30% of the night which persists despite use of continuous positive airway pressure or non-invasive positive pressure ventilation devices.

Note: Hypoxemia is evidenced by any of the qualifying laboratory values obtained while breathing room (ambient) air unless contraindicated:

  1. Adults:
    1. Arterial partial pressure of oxygen (PaO2) equal to or less than 55 mm Hg or SaO2 equal to or less than 88%; or
    2. ArterialPaO2 of 56-59 mm Hg or SaO2 equal to or less than 89% with any of the following conditions
      1. Cor pulmonale; or
      2. Dependent edema secondary to right heart failure; or
      3. Erythrocytosis with hematocrit greater than 56%; or
      4. Pulmonary hypertension.
  2. Infants and Children
    1. PaO2 of equal to or less than 60 mm Hg; or
    2. SaO2 of equal to or less than 92%.

Not Medically Necessary:

Home oxygen therapy is considered not medically necessary for any of the following indications, including but not limited to:

  1. Severe peripheral vascular disease with clinically evident desaturation in one or more extremities in the absence of hypoxemia; or
  2. Terminal illness not affecting the respiratory system; or
  3. Treatment of angina pectoris or dyspnea in the absence of documented associated cor pulmonale or hypoxemia; or
  4. The use of preset regulators used with portable oxygen systems.
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

 

Equipment

E0424-E0425

Stationary compressed gaseous oxygen system

E0430-E0431

Portable gaseous oxygen system

E0433

Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge

E0434-E0435

Portable liquid oxygen system

E0439-E0440

Stationary liquid oxygen system

E0550

Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery

E0555

Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter

E0560

Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery

E0580

Nebulizer, with compressor, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E1353

Regulator

E1354

Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each

E1355

Stand/rack

E1356

Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each

E1357

Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each

E1358

Oxygen accessory, DC power adaptor for portable concentrator, any type, replacement only, each

E1390-E1391

Oxygen concentrator single/dual delivery port

E1392

Portable oxygen concentrator, rental

E1405-E1406

Oxygen and water vapor enriching system

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

 

 

 

Contents

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

S8120

Oxygen contents, gaseous, 1 unit equals 1 cubic foot

S8121

Oxygen contents, liquid, 1 unit equals 1 pound

 

 

 

Supplies

A4615

Cannula, nasal

A4616

Tubing (oxygen), per foot

A4619

Face tent

A4620

Variable concentration mask

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Home oxygen therapy administered at concentrations greater than air external to a building or device (ambient or room air) is intended to treat or prevent symptoms and manifestations of hypoxemic or non-hypoxemic medical conditions that are known to clinically improve with oxygen.

Arterial oxygen saturation of hemoglobin (SaO2) can be measured by arterial blood gas (ABG) sampling or pulse oximetry. The healthcare practitioner orders the testing type and frequency. In adults and children (excluding premature infants), normal values of SaO2 are 94% to 100% (NIH, 2018).

For the diagnosis of cluster headache, oxygen inhalation (100%) delivered at a rate of 7 to 10L/min. for 15 minutes through a loose-fitting facemask is considered to be a safe and effective, first-line treatment for acute attacks. High-flow oxygen has been shown to abort the headache within several minutes.

Oxygen equipment alternatives include three types of systems to provide home oxygen:

With all of these systems, oxygen is inhaled through a mask or more commonly, a nasal cannula. Oxygen conserving devices can be used with compressed or liquid oxygen. The most popular oxygen conserving devices are demand inspiratory flow systems. These devices use a sensor to detect when inspiration begins and deliver oxygen only during inspiration, thus conserving oxygen during exhalation.

Definitions

Bronchiectasis: A condition characterized by the loss of smooth muscle and elasticity of segments of the bronchial tubes.

Bronchiolitis: An inflammation of the bronchioles, the smallest air passages of the lungs, usually caused by a virus.

Cor pulmonale: Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.

Hypoxemic: An oxygen deficiency in arterial blood.

References

Peer Reviewed Publications:

  1. Bailey RE. Home oxygen therapy for treatment of patients with chronic obstructive pulmonary disease. Am Fam Physician. 2004; 70(5):864-865.
  2. Beck E, Sieber WJ, Trejo R. Management of cluster headache. Am Fam Physician. 2005; 71(4):717-724.
  3. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009; 302(22):2451-2457.
  4. Halstead S, Roosevelt G, Deakyne S, Bajaj L. Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis. Pediatrics. 2012; 129(3):e605-e610.
  5. MacLean JE, Fitzgerald DA. A rational approach to home oxygen use in infants and children. Paediatric Respir Rev. 2006; 7(3): 215-222.
  6. Matharu M, Silver N. Cluster headache. Clin Evid (Online). 2008; pii: 1212.
  7. Tie SW, Hall GL, Peter S, et al. Home oxygen for children with acute bronchiolitis. Arch Dis Child. 2009; 94(8):641-643.
  8. Uronis HE, Currow DC, McCrory DC, et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer. 2008; 98(2):294-299.
  9. Wilt TJ, Niewoehner D, MacDonald R, Kane RL. Management of stable chronic obstructive pulmonary disease: a systematic review for a clinical practice guideline. Ann Intern Med. 2007; 147(9):639-653.

Government Agency, Medical Society, and other Authoritative Publications:

  1. Ameer F, Carson KV, Usmani ZA, Smith BJ. Ambulatory oxygen for people with chronic obstructive pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014;(6):CD000238.
  2. Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2007; 131(6):1917-1928.
  3. Balfour-Lynn IM, Field DJ, Gringras P, et al. British Thoracic Society (BTS) guidelines for home oxygen in children. Thorax. 2009; 64 (2):ii1-26.
  4. Bradley JM, O'Neill B. Short-term ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(4):CD004356.
  5. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Home use of oxygen. NCD #240.2. Effective October 27, 1993. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on July 24, 2018.
  6. Cranston JM, Crockett AJ, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008;(3):CD004769.
  7. Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(4):CD001744.
  8. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (Updated 2018). Available at: http://www.goldcopd.org/. Accessed on July 24, 2018.
  9. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013; 33:629.
  10. National Institutes of Health (NIH). MedLinePlus. Blood gases. Updated 7/9/2018. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003855.htm. Accessed on July 24, 2018.
  11. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3):179-191.  
  12. Wedzicha JA, Miravitlles M, Hurst JR, et al. Management of COPD exacerbations: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2017; 49(3):pii 1600791. Available at: https://www.thoracic.org/statements/copd.php. Accessed on July 24, 2018.
Document History

Status

Date

Action

Revised

09/13/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated formatting in the Clinical Indications section. Updated References section.

Reviewed

11/02/2017

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion and References sections.

Reviewed

11/03/2016

MPTAC review. Updated formatting in the Clinical Indications section. Added Definitions section. Updated Discussion/General Information and References sections.

Reviewed

11/05/2015

MPTAC review. Updated References. Removed ICD-9 codes from Coding section.

Revised

11/13/2014

MPTAC review. Format changes and clarifications throughout Clinical Indications section. Updated Description, Discussion and References sections.

Reviewed

11/14/2013

MPTAC review. Format change to Coding section. Updated References section.

Reviewed

11/08/2012

MPTAC review. Updated Discussion and References. Removed/deleted Index. Updated Coding section with 01/01/2013 HCPCS changes; removed K0741, K0742 deleted 12/31/2012.

Reviewed

11/17/2011

MPTAC review. Clarified acronyms in Clinical Indications. Updated Coding and References.

 

07/01/2011

Updated Coding section with 07/01/2011 HCPCS changes.

Reviewed

11/18/2010

MPTAC review. Updated References.

Revised

11/19/2009

MPTAC review. Clarified and reformatted medically necessary Clinical Indication statements. Revised criteria addressing “erythrocytosis with hematocrit” from greater than 55% to greater than 56%. Removed Place of Service/Duration table. Updated References. Updated Coding section with 01/01/2010 HCPCS changes.

Revised

11/20/2008

MPTAC review. Addition of the following not medically necessary statements for the use of home oxygen therapy: severe peripheral vascular disease with clinically evident desaturation in one or more extremities in the absence of hypoxia; terminal illness not affecting the respiratory system; and, cor pulmonale was added to the “treatment of angina pectoris or dyspnea in the absence of documented associated cor pulmonale or hypoxia” statement. References updated. Updated Coding section with 01/01/2009 HCPCS changes.

 

10/01/2008

Updated Coding section with 10/01/2008 ICD-9 changes.

Revised

11/29/2007

MPTAC review. Clarified and reformatted medically necessary Clinical Indications. Deleted medically necessary criteria for portable systems. Coding updated. References reformatted and updated.

Revised

12/07/2006

MPTAC review. Inclusion of medically necessary criteria for non-continuous oxygen during exercise and sleep. Revised hypoxemia criteria for children. Coding updated; removed HCPCS K0671 deleted 12/31/2005.

Revised

12/01/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations Last Review Date Document Number Title

Anthem, Inc.

 

 

No document

Anthem ME

 

Benefit Detail

Oxygen

WellPoint Health Networks, Inc.

12/02/2004

Clinical Document

Home Oxygen Therapy