Description:
Oxygen is administered by inhalation-utilizing devices that provide controlled oxygen concentrations and flow rates to the patients. Oxygen therapy should maintain adequate tissue and cell oxygenation while trying to avoid oxygen toxicity.

Monitoring of the patient’s condition takes place to assure that the patient is receiving the proper mixtures of gases, mists and aerosols.

Policy:
Oxygen and oxygen supplies are considered MEDICALLY NECESSARY for appropriately selected patients only in cases when oxygen is prescribed by a physician, and the prescription must specify:

1. A diagnosis of the disease requiring use of oxygen.
2. Oxygen concentration and flow rate.
3. Frequency of use (if an intermittent or leave-in oxygen therapy, order must include time limits and specific indications for initiating and terminating therapy).
4. Method of delivery.
5. Duration of use (if the oxygen is prescribed on an indefinite basis, care must be periodically reviewed to determine whether a medical need continues to exist).

Continuous pulse oximetry for home use is considered MEDICALLY NECESSARY durable medical equipment (DME) for members with any of the following indications:

• When weaning the individual from home oxygen
• To use as a screening test to determine if a polysomnography is indicated
• To monitor individuals on a ventilator at home

The use of home pulse oximetry is considered NOT MEDICALLY NECESSARY for all other indications, including, but not limited to, the following:

• Asthma management
• When a change in the individual's physical condition requires an adjustment in the liter flow of their home oxygen needs
• To determine appropriate home oxygen liter flow for ambulation, exercise or sleep
• Solely to diagnose sleep apnea

If the medical necessity criteria for the use of oxygen is met, either liquid or gaseous oxygen are considered medically necessary; however, having both liquid and gaseous oxygen is considered NOT MEDICALLY NECESSARY. (e0442, e0443)

Policy Guidelines:
Oxygen therapy is considered medically necessary for:

1. Severe lung disease, defined as either: a resting arterial oxygen partial pressure (PaO2) below 55 mm Hg; or an O2 saturation less than 90%; or symptoms associated with oxygen deprivation, such as impairment of cognitive processes, restlessness, or insomnia. Examples of severe lung disease include, but are not limited to:
   • Chronic obstructive pulmonary disease (COPD).
   • Pulmonary fibrosis.
   • Cystic fibrosis.
   • Bronchiectasis.
   • Recurring congestive heart failure due to chronic cor pulmonale.
   • Chronic lung disease complicated by erythrocytosis (hematocrit > 56%).
2. Cluster headaches when other treatment fails.
   Oxygen therapy is considered NOT MEDICALLY NECESSARY for the following conditions:
   • Angina pectoris in the absence of hypoxemia
   • Breathlessness without evidence of hypoxemia
   • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities
   • Terminal illnesses that do not affect the lungs

Portable oxygen systems are considered MEDICALLY NECESSARY only if the patient ambulates on a regular basis.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

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