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.
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.