Clinical UM Guideline


Subject:  Home Oxygen Therapy
Guideline #:  CG-DME-18Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

Home oxygen therapy is the home administration of oxygen at concentrations greater than the air external to a building or device (ambient or room air) with the intention of treating or preventing signs and symptoms of hypoxemic (lack of oxygen in the blood) or non-hypoxemic medical conditions that are known to clinically improve with oxygen.

Clinical Indications

Medically Necessary:

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 such as, but not limited to:

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 such as, but not limited to:

Intermittent home oxygen therapy is considered medically necessary for the treatment of cluster headaches.

Supplemental home oxygen therapy is considered medically necessary during exercise when there is documentation of:

Supplemental home oxygen therapy is considered medically necessary during sleep in individuals:

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

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. Arterial PaO2 of 56-59 mm Hg or SaO2 equal to or less than 89% with any of the following conditions:
    • Cor pulmonale
    • Dependent edema secondary to right heart failure
    • Erythrocytosis with hematocrit greater than 56%
    • Pulmonary hypertension

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:

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-E0425Stationary compressed gaseous oxygen system
E0430-E0431Portable gaseous oxygen system
E0433Portable 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-E0435Portable liquid oxygen system
E0439-E0440Stationary liquid oxygen system
E0550Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery
E0555Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
E0560Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery
E0580Nebulizer, with compressor, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter
E1353Regulator
E1354Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each
E1355Stand/rack
E1356Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each
E1357Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each
E1358Oxygen accessory, DC power adaptor for portable concentrator, any type, replacement only, each
E1390-E1391Oxygen concentrator single/dual delivery port
E1392Portable oxygen concentrator, rental
E1405-E1406Oxygen and water vapor enriching system
K0738Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing
  
 Contents
E0441Stationary oxygen contents, gaseous , 1 month's supply = 1 unit
E0442Stationary oxygen contents, liquid , 1 month's supply = 1 unit
E0443Portable oxygen contents, gaseous , 1 month's supply = 1 unit
E0444Portable oxygen contents, liquid , 1 month's supply = 1 unit
S8120Oxygen contents, gaseous, 1 unit equals 1 cubic foot
S8121Oxygen contents, liquid, 1 unit equals 1 pound
  
 Supplies
A4615Cannula, nasal
A4616Tubing (oxygen), per foot
A4619Face tent
A4620Variable concentration mask
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of services on or after 10/01/2014]
 All diagnoses
Discussion/General Information

Home oxygen therapy is the home administration of oxygen at concentrations greater than the ambient air with the intention of treating or preventing the 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. Normal values of SaO2 are 94% to 100%.

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.

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. Dodick DW, Capobianco DJ. Treatment and management of cluster headache. Curr Pain Headache Rep. 2001; 5(1):83-91.
  5. Fussell KM, Ayo DS, Branca P, et al. Assessing need for long-term oxygen therapy: a comparison of conventional evaluation and measures of ambulatory oximetry monitoring. Respir Care. 2003; 48(2):115-119.
  6. Hess D. Detection and monitoring of hypoxemia and oxygen therapy. Respir Care. 2000; 45(1):65-80.
  7. Kacmarek RM. Delivery systems for long-term oxygen therapy. Respir Care. 2000; 45(1):84-92.
  8. MacLean JE, Fitzgerald DA. A rational approach to home oxygen use in infants and children. Paediatric Respir Rev. 2006; 7(3): 215-222.
  9. Matharu M, Silver N. Cluster headache. Clin Evid (Online). 2008; pii: 1212.
  10. Tarpy SP, Celli BR. Long-term oxygen therapy. NEJM. 1995; 333(11):710-714.
  11. Tie SW, Hall GL, Peter S, et al. Home oxygen for children with acute bronchiolitis. Arch Dis Child. 2009; 94(8):641-643.
  12. 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.
  13. 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.
  14. Zielinski J. Long-term oxygen therapy in conditions other than chronic obstructive pulmonary disease. Respir Care. 2000; 45(2):172-176.

Government Agency, Medical Society, and other Authoritative Publications:

  1. American Association for Respiratory Care (AARC). Clinical Practice Guideline. Oxygen therapy in the home or alternative site health care facility. Respir Care. 2007; 52(1):1063-1068.
  2. American Association for Respiratory Care (AARC). Clinical Practice Guideline. Selection of an oxygen delivery device for neonatal and pediatric patients: 2002 revision and update. Respir Care. 2002; 47(6):707-716.
  3. American Thoracic Society/European Respiratory Society Task Force. Standards for the diagnosis and management of patients with COPD. Version 1.2. New York: American Thoracic Society; 2004 [updated 2005 September 8]. Available at: http://www.thoracic.org/clinical/copd-guidelines/resources/copddoc.pdf. Accessed on August 19, 2013.
  4. 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.
  5. 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.
  6. Bradley JM, O'Neill B. Short-term ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005; (4):CD004356.
  7. 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 August 19, 2013.
  8. Cranston JM, Crockett AJ, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008; (3):CD004769.
  9. Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005, (4):CD001744.
  10. Croxton TL, Brady WC. Long term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. Am J Resp Crit Care Med. 2006; 174:373-378.
  11. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (Updated 2013). Available at: http://www.goldcopd.org/. Accessed on August 19, 2013.
  12. May A, Leone M, Afra J, et al. European Federation of Neurological Societies (EFNS) guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol. 2006; 13(10):1066-1077.
  13. National Institute for Clinical Excellence (NICE). CG101 Chronic obstructive pulmonary disease: update (full guideline). October 22, 2010. Available at: http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed on August 19, 2013.
  14. 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.  
  15. Ram FSF, Wedzicha JA. Ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002; (1):CD000238.
  16. Rozen TD, Fishman RS. Inhaled oxygen and cluster headache sufferers in the United States: use, efficacy and economics: results from the United States Cluster Headache Survey. Headache. 2011; 51(2):191-200.
Document History

Status

Date

Action

Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Format change to Coding section. Updated Reference section.
Reviewed11/08/2012MPTAC review. Updated Discussion and References. Removed/deleted Index. Updated Coding section with 01/01/2013 HCPCS changes; removed K0741, K0742 deleted 12/31/2012.
Reviewed11/17/2011MPTAC review. Clarified acronyms in Clinical Indications. Updated Coding and References.
 07/01/2011Updated Coding section with 07/01/2011 HCPCS changes.
Reviewed11/18/2010MPTAC review. Updated References.
Revised11/19/2009MPTAC 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.
Revised11/20/2008MPTAC 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.
 10/01/2008Updated Coding section with 10/01/2008 ICD-9 changes.
Revised11/29/2007MPTAC review. Clarified and reformatted medically necessary Clinical Indications. Deleted medically necessary criteria for portable systems. Coding updated. References reformatted and updated.
Revised12/07/2006MPTAC 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.
Revised12/01/2005MPTAC 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 DetailOxygen
WellPoint Health Networks, Inc.

12/02/2004

Clinical Document

Home Oxygen Therapy