Clinical Guideline - Home Oxygen Therapy Print

1. Description

Home oxygen therapy is the home administration of oxygen at concentrations greater than the ambient air with the intention of treating or preventing the symptoms and manifestations of hypoxemic or non-hypoxemic medical conditions that are known to clinically improve with oxygen.

2. Clinical Indications

2.1. Medically Necessary:

Short term supplemental home oxygen therapy is medically necessary for treatment of hypoxemia-related symptoms with qualifying laboratory values (see Note below) associated with acute conditions such as, but not limited to:

  • Bronchiolitis
  • Chronic obstructive pulmonary disease exacerbation
  • Pneumonia

Long term supplemental home oxygen therapy is medically necessary for treatment of hypoxemia-related symptoms with qualifying laboratory values (see Note below) from chronic lung conditions such as, but not limited to:

  • Bronchiectasis
  • Chronic lung disease (CLD) [formerly named Bronchopulmonary Dysplasia (BPD)]
  • Chronic obstructive pulmonary disease
  • Cystic fibrosis
  • Diffuse interstitial lung disease
  • Pulmonary hypertension
  • Pulmonary neoplasm (primary or metastatic)
  • Recurring congestive heart failure due to chronic cor pulmonale

Intermittent home oxygen therapy is considered medically necessary for the treatment of cluster headaches.

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

  • Desaturation to an SaO2 of ≤88% during exercise; and
  • Improvement in hypoxemia and dyspnea or exercise capacity during exercise while using supplemental oxygen.

Supplemental home oxygen therapy is considered medically necessary during sleep in individuals:

  • With unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure, or erythrocytosis with a hematocrit of >56%; or
  • When obstructive sleep apnea (OSA), other nocturnal apnea, or hypoventilation syndromes have been ruled out and desaturation during sleep to an SaO2 of ≤88% for >30% of the night is documented; or
  • When individuals diagnosed with OSA, other nocturnal apnea, or hypoventilation syndromes have desaturation during sleep to an SaO2 of ≤88% for >30% of the night which persists despite use of continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV) devices.

Note: Hypoxemia is evidenced by any of the qualifying laboratory values obtained while breathing room (ambient) air unless contraindicated:

Adults:

  1. Arterial partial pressure of oxygen (PaO2) ≤55 mm Hg or arterial oxygen saturation (SaO2) ≤88%; or
  2. Arterial PaO2 of 56-59 mm Hg or SaO2 of ≤89% with any of the following conditions:
    • Cor pulmonale
    • Dependent edema secondary to right heart failure
    • Erythrocytosis with hematocrit >56%
    • Pulmonary hypertension

Infants and Children:

  1. PaO2 of ≤60 mm Hg; or
  2. SaO2 of ≤92%.

2.2. Not Medically Necessary:

Home oxygen therapy is considered not medically necessary for any of the following indications, including but not limited to:

  • Severe peripheral vascular disease with clinically evident desaturation in one or more extremities in the absence of hypoxemia
  • Terminal illness not affecting the respiratory system
  • Treatment of angina pectoris or dyspnea in the absence of documented associated cor pulmonale or hypoxemia
  • The use of preset regulators used with portable oxygen systems

3. Discussion/General Information

Home oxygen therapy is the home administration of oxygen at concentrations greater than the ambient air with the intention of treating or preventing the symptoms and manifestations of hypoxemic or non-hypoxemic medical conditions that are known to clinically improve with oxygen.

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. Normal values of oxygen saturation (SaO2) are 94% to 100%.

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 to be a safe and effective, first-line treatment for acute attacks. High-flow oxygen has been shown to abort the headache within several minutes.

Oxygen equipment alternatives include three types of systems to provide home oxygen:

  • Compressed oxygen (tanks)
  • Liquid oxygen
  • 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.

4. 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.

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
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
Code Modifiers
QE Prescribed amount of oxygen is less than one liter per minute (LPM)
QF Prescribed amount of oxygen exceeds 4 liters per minute (LPM) and portable oxygen is prescribed
QG Prescribed amount of oxygen is greater than four liters per minute (LPM)
QH Oxygen conserving device is being used with an oxygen delivery system
ICD-9 Diagnosis
Including, but not limited to, the following:
162.3-162.9 Malignant neoplasm bronchus or lung
165.0-165.9 Malignant neoplasm of other and ill-defined sites within the respiratory system
197.0 Secondary malignant neoplasm of lung, bronchus
209.21 Malignant carcinoid tumor of the bronchus and lung
277.02 Cystic fibrosis with pulmonary manifestations
339.00-339.02 Cluster headaches
416.0-416.9 Chronic pulmonary heart disease (Pulmonary hypertension, cor pulmonale)
428.0-428.9 Heart failure
466.0-466.19 Acute bronchitis and bronchiolitis
480.0-486 Pneumonia
490-496 Chronic obstructive pulmonary disease (COPD)
515 Post inflammatory pulmonary fibrosis
770.7 Chronic respiratory disease arising in the perinatal period (bronchopulmonary dysplasia)
786.00-786.09 Dyspnea and respiratory abnormalities
799.01-799.1 Asphyxia and hypoxemia, respiratory arrest
V46.2 Other dependence on machines; supplemental oxygen

 

ARTICLE REFERENCE: http://www.empireblue.com/medicalpolicies/guidelines/gl_pw_a053649.htm