BlueCross and BlueShield of Montana Medical Policy/Codes
Oxygen For Home Use
Chapter: Durable Medical Equipment
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Oxygen is an effective prescription drug for hypoxemic patients with chronic obstructive pulmonary disease (COPD) and may be used outside the hospital setting for patients who meet the criteria for home oxygen therapy.   A physician’s prescription will list flow rate, how much oxygen per minute (liters per minute), and when to use the oxygen.  

There are three common ways of providing home oxygen therapy: 

  • Compressed gas; oxygen stored in a various sized cylinders equipped with a regulator that controls the flow rate.
  • Liquid oxygen; oxygen stored as very cold liquid in a vessel.  The liquid converts to a gas when released. 
  • Oxygen concentrator; an electrically powered device that separates the oxygen out of the air, concentrates it, and stores it.
Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Blue Cross and Blue Shield of Montana (BCBSMT) may consider home oxygen therapy and supplies medically necessary when ALL the following coverage conditions are met:

1.  The treating physician has determined that the patient has a severe lung disease or hypoxia related symptoms that might be expected to improve with oxygen therapy, AND

2.  The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, AND

3.  The qualifying blood gas study was obtained under the following conditions:

  • If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, OR
  • If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the patient is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, AND

4.  Alternative treatment measures have been tried or considered and deemed clinically ineffective, AND

5.  The patient’s blood gas study must fall into one of the following group criteria ranges:

  • Group I criteria: PO2 at or below 55mm Hg or O2 saturation at or below 88 percent taken:
    • At rest (awake) OR
    • During sleep for a patient who doesn’t meet # 1 above.  (Coverage will be provided for nocturnal use only), OR
    • During sleep with a decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, associated with symptoms attributable to hypoxemia (e.g., cor pulmonale, “P” pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), OR
    • During exercise for a patient who doesn’t meet #1 above.  (Oxygen would be covered during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air).
  • Group II criteria: an arterial PO2 of 56-59 MM Hg, or O2 saturation at or below 89 percent at rest (awake), during sleep for at least 5 minutes (does not have to be continuous), or during exercise (as described under Group I criteria), AND any of the following:
    • Dependent edema suggesting congestive heart failure, OR
    • Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), OR
    • Erythrocythemia with a hematocrit greater than 56 percent.

NOTE: Initial coverage for patients meeting Group I and II criteria is limited to 12 months or the physician specified length of need, whichever is shorter.  Prescription must be renewed on an annual basis.

Home oxygen therapy and supplies are considered medically necessary for infants and children with a PO2 less than or equal to 60mmHg or O2 saturation at or below 92%.

Home oxygen therapy and supplies are considered medically necessary for the treatment of cluster headaches.

Oxygen therapy and associated supplies are not considered medically necessary if any of the following conditions exist:

  • Angina pectoris in the absence of hypoxemia.
  • Dyspnea without cor pulmonale or evidence of hypoxemia.
  • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. 
  • Terminal illnesses that do not affect the respiratory system.

A portable oxygen system is considered medically necessary:

  • When the patient is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise.
  • As a backup system (i.e. compressed gas cylinders) in the event of an extended power failure for patients using oxygen concentrators.

A qualifying blood gas study (arterial blood gas (ABG) test or an oximetry test) must be performed by qualified provider (a laboratory, an independent diagnostic testing facility, or a physician).  Blood gas studies performed by a supplier are not acceptable.

Policy Guidelines

Portable Oxygen Contents:  Allowed separately if the patient rents or owns a portable system and owns a concentrator, OR has no stationary system.

Travel Oxygen: It is the patient’s responsibility to arrange for oxygen when traveling outside of their supplier’s usual service area. Oxygen services furnished by an airline are noncovered services. 

Rationale

Literature on patients with continuous hypoxemia and COPD supports the use of supplemental oxygen to improve survival.  It is said to improve pulmonary hemodynamics and extend the life of the patient.   Additionally, in patients with hypoxemia, a select group may show improvement in neuropsychologic function when provided with supplemental oxygen.   Two controlled studies have documented survival benefits of oxygen therapy in COPD patients whose PaO2 is <55 mm Hg:  the British Medical Research Council study and the Nocturnal Oxygen Therapy Trial (NOTT).   These randomized controlled clinical trials conducted in the late 1970’s established the scientific foundation for long term oxygen therapy.

In patients with borderline hypoxemia (PaO2>60mmHg), the scientific literature is less clear in terms of improvement in function.  Studies have shown that nocturnal distortion occurs in 25% to 45% of patients with severe COPD who are not hypoxemic while awake.  Nocturnal oxygen therapy is recommended for such patients who have congestive heart failure, cor pulmonale, or erythrocytosis.  Oxygen therapy during exercise should be prescribed for patients with severe COPD who become hypoxemic only while exercising.  This therapy can assist in rehabilitation and allow increased activity level. 

When compared to being in the hospital, living at home with added oxygen therapy allows control of daily life and generally improves quality of life. 

2009 Update

A search of peer reviewed literature through September 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies           

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.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Refer to ICD-9 manual.

Procedural Codes: E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0442, E0443, E0444, E0446, E1353, E1354, E1356, E1357, E1358, E1362, E1390, E1392, K0738, K0740, K0741, K0742
References
  1. American Thoracic Society, Standards for the Diagnosis and Care of Patients with Chronic Obstructive Pulmonary Disease, American Journal of Respiratory Critical  Care Medicine, 1995 Volume 152:S77-120.
  2. Petty T.L., Bliss P.L. Ambulatory oxygen therapy, exercise, and survival with advanced chronic obstructive pulmonary disease (the Nocturnal Oxygen Therapy Trial revisited). Resp Care 2000; 45:204-11.
  3. Crockett A.J., Cranston J.M., et al. A review of long-term oxygen therapy for chronic obstructive pulmonary disease, Respir Med. 2001 Jun; 95(6):437-43.
  4. Eaton T., Garrett J.E., Ambulatory oxygen improves quality of life of COPD patients: a randomized controlled study, Eur Respir J (2002 August) 20(2):306-12.
  5. Lippincott, Williams & Wilkins, Improving Health-Related Quality of Life in Chronic Obstructive Pulmonary Disease, Curr Opin Pulm Med (10)2:120-7, 2004.
  6. Crockett A.J., Cranston J.M., et al. Domiciliary oxygen for chronic obstructive pulmonary disease (Cochrane Review), The Cochrane Library, Issue 2, 2004.
History
August 2013  New 2013 BCBSMT medical policy.
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Oxygen For Home Use