Clinical Policy: Oxygen Therapy in the Home Reference Number: CP.MP.485

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1 Clinical Policy: Reference Number: CP.MP.485 Effective Date: 09/04 Last Review Date: 09/17 Coding Implications Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description This policy describes the medical necessity requirements for oxygen therapy in the home. This includes the administration of oxygen at concentrations greater than that in room air with the intent of treating or preventing the symptoms and manifestations of severe hypoxia. Policy/Criteria I. It is the policy of Health Net of California that oxygen therapy in the home is medically necessary for those with significant hypoxemia who meet all of the following criteria: A. Health Conditions 1. Short term - severe hypoxemia caused by acute pulmonary illnesses or exacerbations of chronic pulmonary illnesses such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD). 2. Long term - severe hypoxemia caused by progressive lung disease, COPD, interstitial lung disease, or pulmonary lymphangitic spread of carcinoma or by severe congestive heart failure B. Laboratory Evidence If inpatient hospitalization and request is for oxygen at discharge, results must be the last test performed within two days of discharge. If tests performed outpatient for long term use, member should be in a stable state, not during an exacerbation, of the underlying pulmonary illness or other illness. Must meet one of the following: 1. An arterial PO2 55 mm Hg or an arterial oxygen saturation 88%, taken at rest, breathing room air; or 2. For stationary oxygen therapy during sleep, an arterial PO2 55 mm Hg or an arterial oxygen saturation 88%, for at least 5 minutes during sleep for a patient who demonstrates an arterial PO2 56 mm Hg, or an arterial oxygen saturation 89%, while awake; or 3. For stationary oxygen therapy during sleep, a decrease in arterial PO2 > 10 mm Hg or in arterial oxygen saturation > 5% from baseline saturation, for at least 5 minutes during sleep, associated with signs or symptoms reasonably attributable to hypoxemia, such as cor pulmonale, P pulmonale on EKG, pulmonary hypertension or polycythemia (hematocrit > 55%); or 4. For portable oxygen therapy to improve a member s exercise capability, an arterial PO2 55 mm Hg or an arterial oxygen saturation 88%, taken during exercise for a patient who demonstrates an arterial PO2 56 mm Hg or arterial oxygen saturation 89% while awake at rest; or 5. An arterial PO2 of mm Hg or an arterial oxygen saturation of 89%, while awake at rest, if there is evidence of: a. Congestive heart failure; or Page 1 of 8

2 b. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or P pulmonale on EKG; or c. Erythrocythemia (polycythemia) with a hematocrit 56%. C. Medical Documentation Initial claims for oxygen therapy must also include the results of a blood gas study that has been ordered and evaluated by the attending physician. This is usually in the form of a measurement of the partial pressure of oxygen (PO2) in arterial blood. A measurement of arterial oxygen saturation obtained by ear or pulse oximetry, however, is also acceptable when ordered and evaluated by the attending and performed under his or her supervision or when performed by a qualified provider or supplier of laboratory services. When the arterial blood gas and the oximetry studies are both used to document the need for home oxygen therapy and the results are conflicting, the arterial blood gas study is the preferred source of documenting medical need. The conditions under which the laboratory tests are performed must be specified in writing and submitted with the initial claim. A repeat arterial blood gas and/or oximetry study is necessary when evidence indicates that an oxygen recipient has undergone a major change in their condition relevant to home use of oxygen. A portable oxygen system would be considered medically necessary by itself or to use in addition to a stationary oxygen system when the patients mobility regularly exceeds the limits of a stationary oxygen system and the qualifying blood gas study was performed while at rest, awake, or during exercise. Portable oxygen systems would be considered medically necessary when it is provided only as a backup to a stationary oxygen system. The treating physician must provide clinical notes that indicate the patient is receiving necessary treatment for the underlying disease. This includes therapy for pulmonary secretions (pulmonary toilet), bronchodilators, inhaled steroids and antibiotics for intercurrent pulmonary infections. A physician s certification of medical necessity for oxygen equipment must include all of the following: 1. The results of specific testing before medical necessity can be determined. 2. Claims for oxygen must also be supported by documentation in the patient s medical record. Separate documentation is used with electronic billing. A prescription for Oxygen PRN does not meet these criteria. This documentation may be in the form of a prescription written by the patient s attending physician who has recently examined the patient (normally within a month of the start of therapy) and must specify: a. A diagnosis of the disease requiring home use of oxygen; and b. The oxygen flow rate; and c. Specification of the type of oxygen delivery system to be used (i.e., gas, liquid, or concentrator), the means of oxygen delivery (mask, nasal, cannula, etc.) and the Page 2 of 8

3 specifics of varying flow rates, and/or the noncontinuous use of oxygen as necessary; and d. An estimate of the frequency, duration of use (e.g., 2 liters per minute, 10 minutes per hour, 12 hours per day), and duration of need (e.g., 6 months or lifetime). D. Reassessment of Oxygen Needs Reassessment of oxygen needs through pulse oximetry at rest while breathing room air is required and must be performed at three months by a participating oxygen-qualifying company that is in no way connected to the company supplying the oxygen therapy. If the patient still qualifies for oxygen therapy according to the criteria above, another pulse oximetry at rest while breathing room air is required at one (1) year after the initiation of therapy. For patients initially meeting criteria, the patient must be seen AND re-evaluated by the treating physician within 90 days prior to the date of any Recertification. If the physician visit is not obtained within the 90-day window but the patient continues to use oxygen AND the visit is obtained at a later date, coverage would resume beginning with the date of that visit. If at any time the patient fails to meet the criteria above, we would consider further oxygen therapy not medically necessary. E. It is the policy of health plans affiliated with Centene Corporation that oxygen therapy in the home is considered not medically necessary for any of the following indications, including but not limited to: 1. Arterial PO2 levels 60 mm Hg, or arterial blood oxygen saturation 90%; or 2. Severe peripheral vascular disease with clinically evident desaturation in one or more extremities in the absence of hypoxemia; or 3. Terminal illness not affecting the respiratory system; or 4. Treatment of angina pectoris or dyspnea in the absence of documented associated cor pulmonale or hypoxemia. Background Home oxygen therapy has been shown to prevent heart failure in individuals with severe lung disease and significant hypoxemia. Outcome is determined by clinical and physiologic assessment to establish adequacy of patient response to therapy. Arterial oxygen saturation of hemoglobin (SaO 2 ) can be measured by arterial blood gas (ABG) sampling or pulse oximetry. For ongoing evaluation or reassessment, additional arterial blood gas analysis is indicated whenever there is a major change in clinical status that may be cardiopulmonary related. Arterial blood gas measurements should be repeated in 1-3 months after oxygen therapy is begun in a clinically unstable patient to determine the need for ongoing oxygen therapy. Guideline Recommendations Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) on oxygen therapy notes: "The long term administration of oxygen (> 15 hours/ day) to patients with chronic respiratory failure has been shown to increase survival with severe resting hypoxemia: Page 3 of 8

4 Arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88%, with or without hypercapnia, confirmed twice over a 2 week period; or Arterial PO2 between 55 and 60 mm Hg or arterial oxygen saturation of 88% if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure or polycythemia (hematocrit > 55 %). 2 Coding Implications This clinical policy references Current Procedural Terminology (CPT ). CPT is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2015, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT Description Codes Gas, blood, any combination of ph, PCO2, PO2, CO2, HCO3 (including calculated 01 saturation) Noninvasive ear or pulse oximetry for oxygen saturation; single determination Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (e.g., during exercise) Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure) HCPCS Description Codes A4606 Oxygen probe for use with oximeter device, replacement A4615 Cannula, nasal A4616 Tubing (oxygen), per foot A4617 Mouth piece A4620 Variable concentration mask E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable Page 4 of 8

5 HCPCS Description Codes liquid oxygen container, includes portable containers, regulator, flowmeter, humidifer, cannula or mask and tubing, with and without supply reservoir and contents gauge E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing 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 E0445 Oximeter device for measuring blood oxygen levels non-invasively E0455 Oxygen tent, excluding croup or pediatric tents E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter E1353 Regulator E1355 Stand/rack E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate E1391 Oxygen concentrator, dual delivery port, capable of delivering 85percent or greater oxygen concentration at the prescribed flow rate, each E1392 Portable oxygen concentrator, rental ICD-10-CM Diagnosis Codes that Support Coverage Criteria ICD-10-CM Description Code A15.0- Respiratory tuberculosis A15.8 B59 Pneumocystosis C Malignant neoplasm of bronchus and lung C34.92 C38.1 Malignant neoplasm of anterior mediastinum C38.2 Malignant neoplasm of posterior mediastinum C38.4 Malignant neoplasm of pleura C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura Page 5 of 8

6 C39.0 Malignant neoplasm of upper respiratory tract, part unspecified C39.9 Malignant neoplasm of lower respiratory tract, part unspecified C Secondary malignant neoplasm of lung C78.2 C78.39 Secondary malignant neoplasm of other respiratory organ E84.0 Cystic fibrosis with pulmonary manifestations G70.01 Myasthenia gravis with (acute) exacerbation I27.0 Primary pulmonary hypertension I27.81 Cor pulmonale (chronic) J41.0-J41.8 Simple and mucopurulent chronic bronchitis J42 Unspecified chronic bronchitis J43.0-J43.9 Emphysema J44.0-J44.9 Other chronic obstructive pulmonary disease J84.10 Pulmonary fibrosis, unspecified Reviews, Revisions, and Approvals Date Approval Date Policy placed on new template 9/16 9/16 Update no changes 9/17 9/17 References 1. American Association for Respiratory Care (AARC) Clinical Practice Guideline. Oxygen Therapy in the Home or Alternate Site Health Care Facility 2007 Revision & Update. Available at: 2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. January Available at: 3. Hayes. Health Technology Brief. Continuous Pulse Oximetry for Managing Home Oxygen Therapy in Adults. January 22, Archived Myint PK, Lowe D, Stone RA, et al. U.K. National COPD Resources and Outcomes Project 2008: patients with chronic obstructive pulmonary disease exacerbations who present with radiological pneumonia have worse outcome compared to those with non-pneumonic chronic obstructive pulmonary disease exacerbations. Respiration. 2011;82(4): Tiep B, Carter R. Long-term supplemental oxygen therapy. UpToDate. October 9, Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical Page 6 of 8

7 practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. Page 7 of 8

8 Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at for additional information Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 8 of 8

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