Clinical UM Guideline |
Subject: Home Oxygen Therapy | |
Guideline #: CG-DME-18 | Publish Date: 10/01/2025 |
Status: Reviewed | Last Review Date: 08/07/2025 |
Description |
This document addresses the clinical indications for use of home oxygen therapy.
Clinical Indications |
Medically Necessary:
Note: Hypoxemia is evidenced by any of the qualifying laboratory values obtained while breathing room (ambient) air unless contraindicated:
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.
When services may be Medically Necessary when criteria are met:
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 |
E0447 |
Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm) |
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 |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
Summary
Home oxygen therapy involved the delivery of oxygen gas via nasal canula or facemask to individuals with conditions resulting in impaired pulmonary or ventilation function. Recent studies and guidelines affirm the efficacy of home oxygen therapy for certain medical conditions, including a 2009 trial showing reduced hospital stays for children with acute bronchiolitis on home oxygen. Guidelines from the American College of Physicians (ACP), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), and European Respiratory Society (ERS), the British Thoracic Society (BTS), and the American Society of Clinical Oncology (ASCO) recommend oxygen therapy for conditions like COPD, pulmonary hypertension, and bronchiectasis, among others. The use of pulse oximeters to measure arterial oxygen saturation and have faced scrutiny for potential inaccuracies in readings, particularly in individuals with darker skin pigmentation. The Australian Therapeutic Goods Administration and the U.S. Food and Drug Administration (FDA) have highlighted these concerns, emphasizing careful interpretation of oximeter readings and ongoing research to address these discrepancies. Recommendations include coordinating pulse oximetry with comprehensive clinical evaluations to ensure effective management of oxygen therapy for diverse populations.
Discussion
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. Oxygen equipment alternatives include three types of systems to provide home oxygen: compressed oxygen (tanks), liquid oxygen, and oxygen concentrators. 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.
A 2009 prospective, randomized controlled trial (RCT) by Tie compared home oxygen therapy (n=22) to traditional inpatient hospitalization (n=22) for children with acute bronchiolitis. There was 1 child from each arm which required readmission to the hospital. The children in the home oxygen therapy group spent less time in a hospital bed (55.2 hours) compared to those who were inpatient in the hospital (96.9 hours). The authors concluded that the use of home oxygen therapy is a feasible option for the management of acute bronchiolitis in children with acute bronchiolitis.
A 2011 clinical practice guideline on the diagnosis and management of stable chronic obstructive pulmonary disease from the ACP, ACCP, ATS, and ERS (Qaseem, 2011) recommends oxygen therapy for those individuals with chronic obstructive pulmonary disease (COPD) who have severe resting hypoxemia (defined as partial pressure of oxygen [PaO2] less than or equal to 55 mm Hg or oxygen saturation [SpO2] less than or equal to 88%).
A 2018 BTS (Hill, 2018) guideline for bronchiectasis in adults recommends consideration of long-term oxygen therapy for those with bronchiectasis and respiratory failure.
For those with chronic lung disease, the 2021 clinical practice guideline by the ATS (Jacobs, 2021) recommends long-term oxygen in persons with COPD or interstitial lung disease with severe chronic resting hypoxemia.
In 2007 the ACCP published guidelines for treatment of pulmonary artery hypertension. Recommendations include use of supplemental oxygen to maintain oxygen saturation of greater than 90% at all times.
An ASCO guideline for dyspnea published in 2021 by Hui recommends supplemental oxygen for those individuals with advanced cancer and hypoxemia.
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 a safe and effective first-line treatment for acute attacks (Cohen, 2009). High-flow oxygen has been shown to abort the headache within several minutes.
The 2021 Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) on home use of oxygen notes coverage is provided for use of oxygen during sleep if an arterial partial pressure of oxygen (pO2) is at or below 55 mm Hg, or if an arterial oxygen saturation is at or below 88%, taken during sleep. Coverage is also provided for an individual who has an arterial pO2 at or above 56 mm Hg, or has an arterial oxygen saturation at or above 89%, while awake; or a greater than normal fall in oxygen level during sleep. They also note coverage is provided during exercise if the use of oxygen improves the hypoxemia that was demonstrated during exercise when breathing room air. Coverage is also provided for those with dependent edema suggestive of congestive heart failure, pulmonary hypertension or cor pulmonale and erythrocythemia with a hematocrit greater than 56%. While pneumonia is not specifically addressed, the guideline indicates home oxygen therapy is covered for acute or chronic conditions, short or long-term, when hypoxemia is present.
In 2015, the BTS published guidelines for the use of home oxygen in adults (Hardinge, 2015). Recommendations include long-term oxygen therapy for individuals with COPD, interstitial lung disease, cystic fibrosis, and pulmonary hypertension.
Additional guidelines for home oxygen therapy were published in 2019 by the ATS. These guidelines were specific to children. The recommendations note “there is a striking lack of empirical evidence regarding implementation, monitoring, and discontinuation of supplemental oxygen therapy.” However the guidelines also noted the recommendations were based on “scant empirical evidence, expert opinion, and clinical experience to aid clinicians in the management of these complex pediatric patients and identified important areas for future research.” Strong recommendations for home oxygen therapy include cystic fibrosis, bronchopulmonary dysplasia, sleep disordered breathing, pulmonary hypertension, and interstitial lung disease.
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, 2024).
Pulse Oximeter-Related Issues
There has been interest in how multiple factors, including skin pigmentation, can impact the accuracy of pulse oximeter readings and potentially result in overreliance on pulse oximeter levels and suboptimal treatment management of individuals whose oxygen levels are below normal. The Australian Government Department of Health and Aged Care Therapeutic Goods Administration produced a Medical Device Safety Update regarding the limitations of pulse oximeters and the effect of skin pigmentation in 2022. Pulse oximeter devices work by shining light through the skin. Oxygen transporters in blood reflect light differently depending on how much oxygen they contain. The accuracy of the measurement has been known to be affected by many factors, including skin pigmentation. Other factors include correct fitting of the device, peripheral blood flow, nail coatings, tattoos and dyes, and maintenance and cleaning of the devices.
The Australian safety update noted recent cohort studies and systematic reviews indicating the potential for pulse oximeter readings that may over-estimate oxygen saturation levels in people with darker skin pigmentation (Bickler, 2005; Cabanas, 2022; Feiner, 2007; Sjoding, 2020; Valbuena, 2022). These inaccuracies are greater at lower levels of oxygenation and are more frequently reported in persons with darker skin pigmentation. They also occur at saturation levels where key decisions are often made around supplemental home oxygen therapy (at SaO2 levels of 88-94%) with measures that are 3-4 percentage points above the actual oxygen saturation determined by ABG analysis. The authors propose that the effect in persons with intermediate skin tones may be in between that of darker and fairer skin tones. Investigators also acknowledged disparities in the accuracy of different pulse oximeter devices. The safety report concluded that home use of pulse oximeters is safer and more effective when done as part of coordinated medical management of the individual’s total condition with consideration of all clinical factors when recommending treatment. Clinicians are reminded that pulse oximeter devices may not accurately detect hypoxemia in persons with darker skin tones where oxygen saturations levels may be overestimated. At the present time, there is insufficient available evidence to make recommendations about any specific pulse oximeter devices (Australian Therapeutic Goods Administration, 2022).
On June 21, 2022 the U.S. FDA issued an FDA Safety Communication about Pulse Oximeter Accuracy and Limitations, in which the following was noted:
The FDA continues to evaluate all available information pertaining to factors that may affect pulse oximeter accuracy and performance. Because of ongoing concerns that these products may be less accurate in individuals with darker skin pigmentations, the FDA is planning to convene a public meeting of the Medical Devices Advisory Committee later this year to discuss the available evidence about the accuracy of pulse oximeters, recommendations for patients and health care providers, the amount and type of data that should be provided by manufacturers to assess pulse oximeter accuracy, and to guide other regulatory actions as needed. Further details concerning the agenda, timing, and location of the Advisory Committee meeting will be announced in the coming weeks.
The FDA recommendations provided below have not changed. The FDA will continue to keep the public informed as significant new information or recommendations become available.
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.
Chronic lung disease: A disorder that affects the lungs and other parts of the respiratory system. It usually develops slowly and may get worse over time. Examples include asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, asbestosis, pneumonitis, and other lung conditions.
Chronic obstructive pulmonary disease: A condition caused by damage to the airways or other parts of the lung.
Cluster headaches: A primary headache syndrome characterized by attacks of unilateral excruciating pain, usually in the eye and temple with cranial autonomic symptoms.
Cor pulmonale: Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels.
Cystic fibrosis: A genetic disorder that changes a protein in the body which then affects cells, tissues, and the glands which produce mucus and sweat.
Erythrocytosis: A high concentration of red blood cells.
Hypoxemic: An oxygen deficiency in arterial blood.
Interstitial lung disease: A group of several disorders which can cause scarring in the lungs.
Obstructive sleep apnea: A sleep disorder characterized by repeated episodes of complete (apnea) or partial (hypopnea) collapse of the upper airway.
Pneumonia: An infection of the lungs which causes the air sacs (alveoli) to fill up with pus or fluid.
Pulmonary hypertension: A disorder that results in right ventricular dysfunction and activity impairment which can lead to right sided heart failure.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and other Authoritative Publications:
History |
Status |
Date |
Action |
Reviewed |
08/07/2025 |
Medical Policy & Technology Assessment Committee (MPTAC) review. Revised Discussion/General Information, Definitions, and References sections. |
Reviewed |
08/08/2024 |
MPTAC review. Revised Discussion and References section. |
Reviewed |
08/10/2023 |
MPTAC review. Updated References section. |
Revised |
08/11/2022 |
MPTAC review. The MN criterion D-1. for supplemental home oxygen therapy during exercise was revised to remove the SaO2 level and clarify with presence of hypoxemia during exercise. Information was added to the Discussion section about disparities of SaO2 levels sometimes seen in individuals with darkly pigmented skin. References were updated. |
Reviewed |
08/12/2021 |
MPTAC review. References were updated. |
Reviewed |
08/13/2020 |
MPTAC review. References were updated. Reformatted Coding section. |
Reviewed |
08/22/2019 |
MPTAC review. References were updated. |
|
12/27/2018 |
Updated Coding section with 01/01/2019 HCPCS changes; added E0447. |
Revised |
09/13/2018 |
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 |
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