Home and Long Term Care Oxygen Therapy Criteria

Home and LTC oxygen therapy is the administration of oxygen to treat or prevent signs and symptoms of hypoxemia or medical conditions that are known to clinically improve with oxygen.

Short term supplemental oxygen therapy is considered medically necessary with documentation of qualifying pulse oximetry oxygen saturation (O2 sat) or other qualifying laboratory values associated with acute conditions such as, but not limited to:

• Bronchitis
• Acute exacerbation of chronic obstructive pulmonary disease
• Pneumonia
• Pulmonary embolism
• Acute myocardial infarction
• Congestive heart failure (CHF)
• Pleural effusion

Long term supplemental oxygen therapy is considered medically necessary with documentation of a qualifying pulse oximetry O2 sat or other qualifying laboratory values associated with chronic lung conditions such as, but not limited to:

• Bronchiectasis
• Chronic lung disease
• Cystic fibrosis
• Diffuse interstitial lung disease
• Pulmonary hypertension
• Pulmonary neoplasm
• Chronic CHF or related cor pulmonale
• Pediatric bronchopulmonary dysplasia (BPD)
• Neuromuscular disease

Intermittent home oxygen therapy is considered medically necessary for the treatment of cluster headaches with documentation of clinical history that includes but is not limited to:

• frequency, intensity, and duration of headaches
• other treatment options tried and failed

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

• a desaturation of pulse oximetry O2 sat equal to or less than 88% during exercise
• an improvement in pulse oximetry O2 sat while using supplemental oxygen

Supplemental home oxygen therapy is considered medically necessary during sleep with qualifying overnight oximetry study documenting a desaturation at or below 88% for a cumulative time period of 5 minutes or greater in individuals with conditions such as, but not limited to:

• Unexplained pulmonary hypertension, cor pulmonale, or CHF
• Polycythemia with a hematocrit greater than 56% in adults
• Pediatric polycythemia for those up to age 18 years with a hemoglobin or hematocrit that is more than +2 standard deviations above the mean for age and sex
• Nocturnal hypoventilation related to acute or chronic respiratory conditions
• Obstructive sleep apnea (OSA), other nocturnal apneas, or hypoventilation that persists with the use of non-invasive positive pressure ventilation (NIPPV) devices including CPAP and BiPAP

Hypoxemia is evidenced by any of the qualifying laboratory values obtained while on room air. Pulse oximetry O2 sat studies should be performed on room air unless contraindicated by the physician.

• an arterial pO2 at or below 55 mm Hg or pulse oximetry O2 sat at or below 88% in chronic stable state
• an arterial pO2 of 56-59 mm Hg or O2 sat or below 89% in acute state.

• an arterial pO2 at or below 60 mm HG
• a pulse oximetry O2 sat level at or below 92%
• infants with BPD may have variable oxygen needs. In these cases, appropriate documentation, in the absence of qualifying arterial pO2 or pulse oximetry O2 sat values, must be presented for consideration on a case by case basis

• There is documentation of occurrence of a least five severe to very severe unilateral headache attacks lasting 15-180 minutes each when untreated. Severe pain is defined as pain at a level that prevents ability to function in all activities.

• There is accompanying  documentation of at least one of the following findings involving the same side of the unilateral headache attack:

• Conjunctival injection and/or lacrimation

• Nasal congestion and/or rhinorrhea

• Eyelid edema

• Forehead and facial sweating

• Miosis and/or ptosis

The following HCPC codes require prior approval through this department. The HCPC code description is provided along with information regarding availability for coverage for purchase or monthly rental. This is for informational purposes only. All oxygen supplies are included in the monthly allowable.

*This HCPC code is limited for use in Long Term Care (LTC) facility. The liquid system is included in the LTC per diem rate.

The time span initially considered for approval is based upon the current medical documentation, diagnosis, and the conditions under which the qualifying pO2 level or pulse oximetry O2 sat was obtained. These limitations include, but are not limited to:

• Acute respiratory conditions requiring oxygen therapy will be limited to an initial three month approval and provider should be alerted that a current practitioner progress note that includes the current respiratory status along with a current O2 sat must be included with future renewal requests for O2 therapy.

• Chronic respiratory conditions requiring oxygen therapy will be limited to an initial six month approval. A request for renewal would be considered for an additional six months. A current O2 sat, obtained within that previous 6 months time period, must be provided with the first request for renewal consideration. After the initial first year approval, requests may be approved for one year intervals with submittal of current qualifying O2 sat level.

• Cluster headaches requiring oxygen therapy will be limited to an initial one month consideration. A provider should be alerted that a clinical current progress note that includes frequency, duration, and intensity of headache pattern and response to O2 therapy will be required for all renewal requests. If the headache pattern has decreased to a level that no longer meets criteria, a renewal will not be approved. If the headache pattern persists and there is clinical documentation of a positive response to oxygen therapy, a two month approval will be granted.

Oxygen concentrator prior approvals will be limited to:

• 24 hour continuous oxygen at a minimum liter flow of 1 liter per minute for adult patients and a minimum liter flow of 0.5 liters per minute for pediatric patients. 

• 8 hours nocturnal oxygen liter flow with a minimum liter flow of 1 liter per minute for adult patients and minimum liter flow of 0.5 liters per minute for pediatric patients.

Oxygen concentrators will not be considered for approval for as needed (prn) use. Other oxygen delivery systems are available for prior approval to meet the prn oxygen needs.

In a long term care setting, additional types of oxygen delivery systems and oxygen fills will not be considered when the participant is approved for an oxygen concentrator. In this scenario, all other oxygen delivery systems and oxygen fills are included in the Department’s LTC per diem allowable paid to the facility.

Consideration for approval for oxygen therapy requested for treatment of cluster headaches will be limited to:

• A purchase of stationary gaseous unit (E0425)
• Gaseous stationary content (E0441)

References

• CG-DME-18 Home Oxygen Therapy Medical_Guideline
• American Association for Respiratory Care 
• National Government Services
• Aetna Clinical Policy Bulleting
• HFS Provider Notice September 27, 2012, Oxygen Reimbursement Changes effective December 1, 2012
• HFS Provider Notice October 17, 2013, Oxygen Policy Clarification for Residents of Long Term Care Facilities