Home, domiciliary and portable oxygen - Prestige Health Choice · Home, domiciliary and portable...
Transcript of Home, domiciliary and portable oxygen - Prestige Health Choice · Home, domiciliary and portable...
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Clinical Policy Title: Home, domiciliary and portable oxygen
Clinical Policy Number: 07.02.04
Effective Date: October 1, 2014
Initial Review Date: April 19, 2014
Most Recent Review Date: April 10, 2018
Next Review Date: April 2019
Related policies:
CP# 07.02.01 Pulmonary rehabilitation
CP# 07.01.01 Treatment for obstructive sleep apnea in adults
ABOUT THIS POLICY: Prestige Health Choice has developed clinical policies to assist with making coverage determinations. Prestige Health
Choice’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies, along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Prestige Health Choice when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Prestige Health Choice’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Prestige Health Choice’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Prestige Health Choice will update its clinical policies as necessary. Prestige Health Choice clinical policies are not guarantees of payment.
Coverage policy
Prestige Health Choice considers the use of home, domiciliary, and portable oxygen to be clinically proven
and, therefore, medically necessary for treatment of hypoxemia in members with either severe lung
disease or hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy,
when any of the following criteria are met:
Continuous oxygen therapy (Qaseem, 2011; Raghu, 2011):
Arterial partial pressure of oxygen (PaO2) at or below 55 mm Hg, or arterial oxygen saturation
(SaO2) at or below 88 percent, taken at rest, breathing room air.
PaO2 56 – 59 mm Hg or SaO2 of 89 percent at rest (awake) and evidence of:
- Dependent edema suggesting congestive heart failure.
Policy contains:
Continuous-use oxygen
therapy.
Intermittent oxygen use.
Ambulatory oxygen therapy.
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- Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary
artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on
electrocardiogram.
- Erythrocythemia with a hematocrit greater than 56 percent.
For infants and children, PaO2 at or below 60 mm Hg or SaO2 at or below 92 percent (Balfour-
Lynn, 2009; American Association for Respiratory Care, 2007; Allen, 2003):
During sleep only, when both criteria are met (Balfour-Lynn, 2009; American Association for Respiratory
Care, 2007; Morgenthaler, 2006; American Thoracic Society, 2005; Allen, 2003):
Nocturnal hypoxemia without evidence of daytime hypoxemia defined as either:
- A PaO2 at or below 55 mm Hg, or an SaO2 at or below 88 percent, measured during
sleep for a member who demonstrates a PaO2 at or above 56 mm Hg, or an SaO2 at or
above 89 percent, while awake.
- A greater than normal fall in oxygen level during sleep (a decrease in PaO2 more than
10 mm Hg, or a decrease in SaO2 greater than 5 percent) associated with symptoms
(e.g., impairment of cognitive processes and nocturnal restlessness or insomnia) or
signs (e.g., pulmonary hypertension, cor pulmonale, P pulmonale, or erythrocytosis
with a hematocrit greater than 56 percent) reasonably attributable to hypoxemia.
Other causes of nocturnal hypoxemia (e.g., obstructive sleep apnea, other nocturnal apnea, or
hypoventilation syndromes) have been ruled out or optimally treated according to standard of
care (e.g., continuous positive airway pressure or noninvasive positive pressure ventilation).
During exercise only, when both criteria are met (American Association for Respiratory Care, 2007;
American Thoracic Society, 1999):
• A PaO2 at or below 55 mm Hg or an SaO2 at or below 88 percent, for a patient who
demonstrates an PaO2 at or above 56 mm Hg, or an SaO2 at or above 89 percent, during the day
while at rest.
• Documentation shows supplemental oxygen improves the hypoxemia demonstrated during
exercise while breathing room air.
Short-term use (generally less than 1 month) for other hypoxia-related diagnoses, symptoms, or findings
that might be expected to improve with oxygen such as cognitive impairment, nocturnal restlessness,
croup, or pneumonia (Balfour-Lynn, 2009).
Short-term use for conditions unrelated to hypoxemia (Hardinge, 2015; American Association for
Respiratory Care, 2007):
Cluster headache defined as at least five severe to very severe unilateral headache attacks
lasting 15 minutes ‒ 180 minutes when untreated. The degree or intensity of pain is usually
expressed in terms of its functional consequence and scored on a verbal five-point scale.
Hemoglobinopathies.
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Infants with bronchopulmonary dysplasia who may have variable oxygen needs, to be
considered on a case-by-case basis in the absence of documentation of otherwise qualifying
oxygen saturation values.
Prestige Health ChoicePrestige Health Choice
Prestige Health Choice considers the use of the following oxygen supply systems and associated
administration devices to be medically necessary for members with hypoxemia who meet the above criteria
(Qaseem, 2011; American Association for Respiratory Care, 2007; American Thoracic Society, 2005):
Home, domiciliary and portable
oxygen supply systems Medical necessity criteria
Oxygen concentrators —stationary
and/or portable.
Stationary: For members who do not regularly go beyond the limits of a
stationary oxygen delivery system with 50-ft. tubing or those who use
oxygen only during sleep.
Portable: For members who are regularly (at least monthly) away from
home for durations that exceed the capacity of ambulatory oxygen
systems.
Oxygen cylinders — large reservoir
tanks, H or K cylinders; smaller
cylinders D or E for portability; and
liquid oxygen systems.
Stationary: For members who do not regularly go beyond the limits of a
stationary oxygen delivery system with 50-ft. tubing or those who use
oxygen only during sleep. Cast iron and/or aluminum cylinders.
Portable: For members who occasionally go beyond the limits of a
stationary oxygen delivery system with 50-ft. tubing for less than two hours
per day for most days of the week (minimum two hours/week).
Oxygen transfilling systems: when the medical necessity criteria listed
above for portable oxygen systems are met and the individual is mobile
within the home.
Ambulatory systems that weigh less
than 10 lbs. when filled with oxygen
and are designed to be carried by the
member, and will last for four hours at
a flow equivalent to 2 L/min continuous
flow; e.g., liquid refillable units and
aluminum or fiber-wrapped lightweight
cylinders, with or without oxygen
conserving devices.
For members who regularly go beyond the limits of a stationary oxygen
delivery system with 50-ft. tubing for two hours or more per day and for
most days of the week (minimum six hours/week).
Limitations:
Coverage determinations are subject to benefit limitations and exclusions as delineated by the state
Medicaid authority. The Florida Medicaid website may be accessed at
http://ahca.myflorida.com/Medicaid/.
All other uses of home, domiciliary, and portable oxygen are not medically necessary, including the
following conditions:
Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low
oxygen level in the blood, and there are other preferred treatments.
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Breathlessness without cor pulmonale or evidence of hypoxemia. Although intermittent oxygen
use is sometimes prescribed to relieve this condition, it is potentially harmful and
psychologically addicting.
Severe peripheral vascular disease resulting in clinically evident desaturation in one or more
extremities but in the absence of systemic hypoxemia. There is no evidence that increased PaO2
improves the oxygenation of tissues with impaired circulation.
Terminal illnesses that do not affect the lungs.
Primary treatment for obstructive sleep apnea, other nocturnal apnea, or hypoventilation
syndromes (Qaseem, 2013; Morgenthaler, 2006).
A second oxygen tank (spare tank) is not medically necessary, except for members who are dependent on
either continuous oxygen or an oxygen concentrator.
Portable oxygen is not medically necessary when used only during sleep.
The need for ongoing home, domiciliary, or portable oxygen must be demonstrated by blood gas results or
pulse oximetry performed by the individual’s attending physician or an independent respiratory
practitioner, either:
One month after initiation of therapy for conditions that may be expected to be short-term,
such as pneumonia, asthma, bronchitis, or bronchiolitis.
Three months after initiation of therapy for other conditions to determine acute or chronic
need for oxygen.
Rental of airline oxygen tanks is medically necessary when members meet the criteria for oxygen for home
use listed above and are not allowed to use their own portable oxygen tanks on airplanes.
Alternative covered services:
Smoking cessation programs.
Pharmacologic therapy.
Pulmonary rehabilitation, education, and self-management.
End of life and palliative care.
Surgery and endoscopy.
Background
Home oxygen therapy provides supplemental oxygen for short-term, intermittent use, continuous (long-
term) use, and ambulation with the intent of treating or preventing the symptoms and manifestations of
hypoxia (American Thoracic Society, 2005). Most indications for home oxygen therapy are related to
relieving hypoxia, but medical conditions that respond to supplemental oxygen may benefit from home
use.
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Home oxygen systems are either stationary or ambulatory (American Association for Respiratory Care,
2007). Stationary oxygen systems are delivered by a concentrator, compressed gas, or liquid. The major
disadvantages of liquid oxygen are frequent refilling due to oxygen evaporation, even if not used, and
variable supply of liquid-oxygen systems. Oxygen concentrators are currently the most convenient and
economical method of providing domiciliary long-term oxygen therapy. The choice of system will depend
upon availability, cost, and patient suitability.
Ambulatory oxygen therapy provides oxygen during exercise and for activities of daily living to patients on
long-term oxygen therapy who are mobile and need to, or can, leave the home on a regular basis.
Ambulatory oxygen systems should weigh less than 10 lbs. and provide oxygen at least 2 L/minute for at
least four hours. The patient must be able to carry the device during activities of daily living. The choice of
portable device depends on the patient's mobility and includes continuous oxygen delivery systems, high-
flow nasal cannula, portable oxygen tanks, and oxygen conserving devices (American Thoracic Society,
2005).
Searches
Prestige Health Choice searched PubMed and the databases of:
UK National Health Services Centre for Reviews and Dissemination.
Agency for Healthcare Research and Quality’s Guideline Clearinghouse and evidence-based
practice centers.
The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on March 1, 2018. Search terms were: “Oxygen Inhalation Therapy/therapeutic
use” (MeSH), “Oxygen Inhalation Therapy/therapy” (MeSH), “Home Care Services” (MeSH), “Home Care
Services, Hospital-Based” (MeSH), and the free text terms “continuous oxygen” and “home oxygen.”
We included:
Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and
greater precision of effect estimation than in smaller primary studies. Systematic reviews use
predetermined transparent methods to minimize bias, effectively treating the review as a
scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
Guidelines based on systematic reviews.
Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies
— which also rank near the top of evidence hierarchies.
Findings
The evidence for prescribing long-term oxygen therapy is based on results from two randomized controlled
trials showing a beneficial effect on survival, dyspnea, and functional status in patients with chronic
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obstructive pulmonary disease, few comorbidities, and severe hypoxemia (Medical Research Council, 1981;
Nocturnal Oxygen Therapy Trial, 1980). The rationale for its use in patients with other severe hypoxemic
conditions rests on extrapolation of data from patients with chronic obstructive pulmonary disease. Limited
evidence supports intermittent home oxygen therapy to treat persons with cluster headaches,
hemoglobinopathies, and signs of tissue hypoxia (e.g., pulmonary hypertension, cor pulmonale,
erythrocytosis, or impaired mental status).
There is less certainty regarding the value of home oxygen therapy for patients with mild to moderate
hypoxemia, only arterial desaturation at night, or temporary hypoxemia due to a clinically unstable
condition. Ambulatory oxygen from a liquid source or lightweight cylinders modestly improves disease-
specific quality of life in selected patients who participate in regular outdoor activity. Desaturation only
during exercise or sleep suggests consideration of oxygen therapy specifically under those conditions.
Likewise, patients with adequate PaO2 who have severe dyspnea relieved by low-flow oxygen or patients
who are limited in their exertional capacity but improve their exercise performance with supplemental
oxygen warrant consideration of oxygen therapy.
Palliative oxygen is frequently prescribed to manage dyspnea in people with advanced life-limiting illness,
despite a lack of evidence and clinical practice guidelines supporting its use for patients with PaO2 greater
than 55 mm Hg (American Association for Respiratory Care, 2007). Prescribing tends to be based on
symptoms or patient request irrespective of PaO2 or oximetry. The uncertainty of the benefit of palliative
oxygen has led to inconsistent access and variable utilization. Quality care for people with life-limiting
illness and refractory symptoms requires the judicious use of oxygen through careful monitoring of
symptoms using basic standardized scales, guided by patient preference.
Initiation of oxygen therapy requires direct measurement of arterial blood gas tensions off and on oxygen
therapy for 30 minutes to determine the presence of hypercapnia or respiratory acidosis. Indirect
measurement of oxygen saturation using pulse oximetry is not adequate for initiating long-term oxygen
therapy, but it may be used for titrating oxygen flow over time (American Association for Respiratory Care,
2007; American Thoracic Society, 2005). However, pulse oximetry is an acceptable alternative for infants
and children (Balfour-Lynn, 2009).
The therapeutic goal is to maintain SaO2 greater than 90 percent during rest, sleep, and exertion.
Physiological indications for long-term oxygen therapy include (Qaseem, 2011):
PaO2 less than 55 mm Hg corresponding to an SaO2 at or below 88 percent.
PaO2 of 55 - 59 mm Hg corresponding to an SaO2 of 89 percent and exhibiting signs of tissue
hypoxia, such as pulmonary hypertension, cor pulmonale, erythrocytosis, edema from right
heart failure, or impaired mental status.
PaO2 at or above 60 mm Hg corresponding to an SaO2 at or above 90 percent in persons who
experience desaturation only during exercise or sleep, or with lung disease with severe dyspnea
that responds to oxygen therapy.
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Standards for continuing oxygen therapy depend on whether it is prescribed for the first time during an
acute exacerbation, or at a time when the patient is relatively stable and receiving optimal therapy.
Patients should be evaluated one month after initiation of therapy for conditions that may be expected to
be short-term (e.g., pneumonia, asthma, bronchitis, or bronchiolitis), and after three months to identify
initially eligible patients who may have acute or chronic need and to ensure adherence to the hypoxemia
criteria (American Association for Respiratory Care, 2007). Following a three-month initial evaluation, pulse
oximetry or arterial blood gas results should be reported within 12 months of the initiation of oxygen and
whenever there is an increase in the amount of oxygen or change in the type of oxygen equipment being
requested.
Policy updates:
The long-awaited Long-term Oxygen Treatment Trial (ClinicalTrials.gov number NCT00692198) published
findings for persons with chronic obstructive pulmonary disease who would not meet current criteria for
long-term oxygen therapy (Albert, 2016). Using pulse oximetry, the investigators defined moderate oxygen
desaturation at rest as 89 percent to 93 percent, and during exercise as at least 80 percent for at least five
minutes and less than 90 percent for at least 10 seconds on the six-minute walk test. Long-term oxygen
therapy failed to show significant improvement in time to death or first hospitalization or provide sustained
benefit in health status, lung function, or the six-minute walk test in persons with stable chronic obstructive
pulmonary disease and either moderate resting or exercise-induced oxygen desaturation.
An updated Cochrane review found insufficient evidence to support long-term oxygen therapy in persons
with stable chronic obstructive pulmonary disease and mild or no hypoxemia, again representing persons
who would not meet current criteria for long-term oxygen therapy (Ekstrom, 2016). Another Cochrane
review found insufficient evidence to support using ambulatory and short-burst oxygen for persons with
interstitial lung disease (Sharp, 2016).
Recommendations from the Global Initiative for Chronic Obstructive Lung Disease (2017, updated 2018)
support long-term oxygen therapy in persons with severe resting chronic hypoxemia. They do not
recommend routinely prescribing long-term oxygen therapy for stable patients with chronic obstructive
pulmonary disease and resting or exercise-induced hypoxemia. Rather, prescription for long-term oxygen
therapy should be based on individual assessment of symptoms and future risk of exacerbations. These
results are consistent with previous findings and warrant no changes to the policy at this time.
In 2018, we added several seminal guidelines that have provided the basis for the current standards of care
for prescribing home oxygen therapy for several years (Qaseem, 2011; Raghu, 2011; Balfour-Lynn, 2009;
American Association for Respiratory Care, 2007; Morgenthaler, 2006; Allen, 2003). We clarified the criteria
for medical necessity for supplemental oxygen during sleep. Current guidelines do not recommend
supplemental oxygen as a primary treatment for oxygen desaturation associated with sleep disorders. In
addition to the existing laboratory criteria, we added a statement requiring that other causes of nocturnal
hypoxemia (e.g., obstructive sleep apnea, other nocturnal apnea, or hypoventilation syndromes) be ruled
out or optimally treated according to standard of care (e.g., continuous positive airway pressure or
noninvasive positive pressure ventilation) before oxygen is prescribed for this condition.
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Summary of clinical evidence:
Citation Content, Methods, Recommendations
Global Initiative for
Chronic Obstructive
Lung Disease (2018)
Guideline for chronic
obstructive pulmonary
disease
Key points:
In patients with severe resting chronic hypoxemia, long-term oxygen therapy improves
survival.
For stable patients with chronic obstructive pulmonary disease and mild-to-moderate
resting or exercise-induced hypoxemia, long-term oxygen therapy should not be
prescribed routinely. However, individual patient factors should be considered when
evaluating the need for oxygen (e.g., reduction of symptoms and future risk of
exacerbations).
Recommendation based on results of the Long-term Oxygen Therapy Trial.
Albert (2016)
Long-term Oxygen
Therapy Trial
Key points:
A randomized controlled trial of 738 patients with stable chronic obstructive pulmonary
disease with moderate oxygen desaturation at rest (pulse oximetry [SpO2] 89% to 93%)
or during exercise (SpO2 at or above 80% for at least 5 minutes and less than 90% for
at or above 10 seconds on six-minute walk test) who received long-term oxygen
therapy or no oxygen and were followed for one to six years. In the supplemental-
oxygen group, patients with resting desaturation were prescribed 24-hour oxygen, and
those with desaturation only during exercise were prescribed oxygen during exercise
and sleep.
Long-term oxygen therapy did not improve patient outcomes (time to death or first
hospitalization composite outcome) in the rates of all hospitalizations, exacerbations, or
hospitalizations related to chronic obstructive pulmonary disease, or in measures of
quality of life, lung function, or the six-minute walk test.
Ekstrom (2016)
Cochrane review
Oxygen for
breathlessness in
patients with chronic
obstructive pulmonary
disease who do not
qualify for home oxygen
therapy
Key points:
Systematic review of 28 studies (702 participants); meta-analysis included 18
randomized controlled trials (431 participants).
Overall quality: low. Significant heterogeneity across studies.
Oxygen can relieve dyspnea in mildly hypoxemic and non-hypoxemic patients with
chronic obstructive pulmonary disease who would not otherwise meet criteria for home
oxygen therapy.
Insufficient evidence to support routine home oxygen therapy.
2016 update: added 14 new randomized controlled trials (493 participants). Low-quality
evidence suggests supplemental oxygen can reduce dyspnea during exercise, but not
in the daily life setting or health-related quality of life.
Sharp (2016)
Cochrane review
Ambulatory and short-
burst oxygen for
interstitial lung disease
Key points:
Systematic review of three studies (98 total participants in hospital respiratory
physiology laboratories).
Overall quality: low.
Conflicting results of any beneficial effect of supplemental oxygen on exercise capacity
or exertional dyspnea. No studies examined health-related quality of life, survival,
costs, time-to-exacerbation or -hospitalization, or reported adverse events.
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Citation Content, Methods, Recommendations
Ameer (2014)
Cochrane review
Ambulatory oxygen
therapy in patients with
chronic obstructive
pulmonary disease who
do not meet criteria for
long-term oxygen
therapy
Key points:
Systematic review of four randomized controlled trials (331 participants).
Overall quality: low to moderate. Underpowered, moderate risk of bias based on study
designs.
For patients with chronic obstructive pulmonary disease and moderate hypoxemia,
ambulatory oxygen therapy improves dyspnea after exercise and in the dyspnea and
fatigue domain of quality of life, but inconclusive for improving mortality and exercise
capacity.
Methodologically rigorous randomized controlled trials with sufficient power are
needed.
Petersen (2014)
Oxygen therapy for
cluster headache
Key points:
Systematic review of five small randomized controlled trials and one observational
study.
Efficacy of low-flow oxygen (6 – 7 L/m) ranged 56 percent to 82 percent in three
studies. High-flow oxygen (12 L/min) was effective in 78 percent of attacks in one
study.
Limited evidence that oxygen treatment is effective and safe. However, logistic and
financial concerns restrict access to oxygen in this population.
Elphick (2013)
Cochrane review
Oxygen therapy in
cystic fibrosis
Key points:
Systematic review of 11 randomized controlled trials or quasi-randomized controlled
trials (172 participants): one studied long-term oxygen therapy (28 participants), four
studied oxygen supplementation during sleep by polysomnography, and six studied
oxygen supplementation during exercise.
Short-term oxygen therapy during sleep and exercise improves oxygenation but is
associated with modest and probably clinically inconsequential hypercapnia. There are
improvements in exercise duration, time to fall asleep, and regular attendance at school
or work.
Qaseem (2011, based
on 2007 guideline) for
the American Thoracic
Society
Guideline: diagnosis
and management of
stable chronic
obstructive pulmonary
disease
Key points:
Supplemental oxygen used at or above15 hours daily to maintain a PaO2 greater than
60 mm Hg reduced mortality in patients with severe resting hypoxemia (mean resting
PaO2 at or less than 55 mm Hg).
Supplemental oxygen (9 to 13 hours daily) showed no effect on relative risk for
mortality with use of supplemental oxygen during the day or at night in patients with
similar severity of airflow obstruction but daytime PaO2 greater than 60 mm Hg.
Ambulatory oxygen has no effect on respiratory health-related quality of life measures.
Physiologic indications include cor pulmonale or polycythemia with PaO2 between 55
and 59 mm Hg.
Raghu (2011) for the
American Thoracic
Society
Guideline: idiopathic
pulmonary fibrosis
Key points:
Strong recommendation for long-term oxygen therapy in patients with interstitial
pulmonary fibrosis and clinically significant resting hypoxemia (SpO2 less than 88%); a
PaO2 cutoff could not be determined.
Recommendation based on indirect evidence from studies of chronic obstructive
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Citation Content, Methods, Recommendations
pulmonary disease and very low-quality evidence of improvement in exercise capacity
in patients with resting hypoxemia using oxygen.
Balfour-Lynn (2009) for
the British Thoracic
Society
Guidelines for home
oxygen in children
Key points:
Pulse oximetry should be used to assess hypoxemia and need for oxygen.
Target levels vary with lung condition and age, but in general oxygen therapy should be
given to maintain a SpO2 greater than 93% for children with chronic neonatal lung
disease, although greater than 94% may be appropriate for sickle cell disease and
greater than 90% for cystic fibrosis.
Continuous oxygen therapy may be indicated for a variety of chronic lung conditions or
congenital conditions associated with hypoxemia.
American Association
for Respiratory Care
(2007)
Guideline: oxygen
therapy in the home or
alternate site health
care facility
Key points:
Indicated for hypoxemia in adults, children, and infants older than 28 days as
evidenced by:
- PaO2 at or less than 55 mm Hg or SaO2 at or less than 88% on room air.
- PaO2 of 56-59 mm Hg or SaO2 or pulse oximetry at or less than 89% in
association with specific clinical conditions (e.g., cor pulmonale, congestive
heart failure, or erythrocythemia with hematocrit greater than 56).
- During ambulation, sleep, or exercise, oxygen therapy when SaO2 at or less
than 88%.
- Dyspnea with hypoxemia at end-of-life.
Indicated for other conditions where strong evidence may be lacking (e.g., cluster
headaches) on the order and discretion of the attending physician.
Morgenthaler (2006) for
the American Academy
of Sleep Medicine
Practice parameters for
the medical therapy of
obstructive sleep apnea
Key points:
Oxygen supplementation is not recommended as a primary treatment.
Available studies showed favorable effects on oxygenation, but the effect of oxygen
therapy on apneas, hypopneas, and subjective sleepiness was inconsistent.
Allen (2003) for the
American Thoracic
Society
Statement on the care
of the child with chronic
lung disease of infancy
and childhood
Key points:
Bronchopulmonary dysplasia refers to chronic lung disease subsequent to oxygen
and/or ventilator therapy for respiratory distress syndrome in preterm newborns, or in
full-term newborns subsequent to mechanical ventilation for other neonatal respiratory
conditions.
Chronic lung disease of prematurity refers to other chronic lung diseases of the preterm
infant that can arise after an initial period without an oxygen or ventilatory requirement.
Home oxygen may be indicated for young patients with chronic lung disease of infancy
who experience oxygen desaturation on room air, with target SaO2 levels generally 90-
95% depending on gestational age at birth.
Pulse oximetry is an acceptable oxygen saturation measurement, even in the presence of carbon dioxide retention.
References
Professional society guidelines/other:
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AARC clinical practice guideline. Oxygen therapy in the home or alternate site health care facility--2007
revision & update. Respir Care. 2007; 52(8): 1063 – 1068. Available at:
http://rc.rcjournal.com/content/respcare/52/8/1063.full.pdf. Accessed March 1, 2018.
Allen J, Zwerdling R, Ehrenkranz R, et al. Statement on the care of the child with chronic lung disease of
infancy and childhood. Am J Respir Crit Care Med. 2003; 168(3): 356 – 396. DOI: 10.1164/rccm.168.3.356.
American Thoracic Society. Dyspnea. Mechanisms, assessment, and management: a consensus statement.
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American Thoracic Society. Statement on home care for patients with respiratory disorders. Am J Respir Crit
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From the Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary
disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018. GOLD website.
http://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf.
Accessed March 1, 2018.
Hardinge M, Annandale J, Bourne S, et al. British Thoracic Society guidelines for home oxygen use in adults.
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10.7326/0003-4819-159-7-201310010-00704.
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pulmonary disease: a clinical practice guideline update from the American College of Physicians, American
College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med.
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Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/JRS/ALAT statement: idiopathic pulmonary fibrosis:
evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011; 183(6): 788 –
824. DOI: 10.1164/rccm.2009-040GL.
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diagnosis and management. June, 2010. NICE website.
http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed March 2, 2018.
Peer-reviewed references:
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Desaturation. N Engl J Med. 2016; 375(17): 1617 – 1627. DOI: 10.1056/NEJMoa1604344.
Ameer F, Carson KV, Usmani ZA, Smith BJ. Ambulatory oxygen for people with chronic obstructive
pulmonary disease who are not hypoxaemic at rest. Cochrane Database Syst Rev. 2014; 6: Cd000238. DOI:
10.1002/14651858.CD000238.pub2.
Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial.
Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980; 93(3): 391 – 398. DOI: 10.7326/0003-4819-
93-3-391.
Ekstrom M, Ahmadi Z, Bornefalk-Hermansson A, Abernethy A, Currow D. Oxygen for breathlessness in
patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy.
Cochrane Database Syst Rev. 2016; 11: Cd006429. DOI: 10.1002/14651858.CD006429.pub3.
Elphick HE, Mallory G. Oxygen therapy for cystic fibrosis. Cochrane Database Syst Rev. 2013; 7: Cd003884.
DOI: 10.1002/14651858.CD003884.pub4.
Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and
emphysema. Report of the Medical Research Council Working Party. Lancet. 1981; 1(8222): 681 – 686. DOI:
10.1016/S0140-6736(81)91970-X.
Petersen AS, Barloese MC, Jensen RH. Oxygen treatment of cluster headache: a review. Cephalalgia. 2014;
34(13): 1079 – 1087. DOI: 10.1177/0333102414529672.
Sharp C, Adamali H, Millar AB. Ambulatory and short-burst oxygen for interstitial lung disease. Cochrane
Database Syst Rev. 2016; 7: Cd011716. DOI: 10.1002/14651858.CD011716.pub2.
CMS National Coverage Determinations:
240.2.2 Home Oxygen Use to Treat Cluster Headache (CH). CMS website. http://www.cms.gov/medicare-
coverage-database/details/ncd-details.aspx?NCDId=343&ver=1. Accessed March 2, 2018.
240.2 Home Use of Oxygen. CMS website. http://www.cms.gov/medicare-coverage-database/details/ncd-
details.aspx?NCDId=169&ver=1. Accessed March 2, 2018.
240.2.1 Home Use of Oxygen in Approved Clinical Trials. CMS website. https://www.cms.gov/medicare-
coverage-database/details/ncd-details.aspx?NCDId=312&ver=1. Accessed March 2, 2018.
Local Coverage Determinations:
13
A52514 Oxygen and Oxygen Equipment - Policy Article. CMS website. https://www.cms.gov/medicare-
coverage-database/details/article-details.aspx?articleId=52514&ver=9 . Accessed March 2, 2018.
L33797 Oxygen and Oxygen Equipment. CMS website. https://www.cms.gov/medicare-coverage-
database/details/lcd-details.aspx?LCDId=33797&ver=10. Accessed March 2, 2018.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill
accordingly.
CPT Code Description Comment
N/A
ICD-10 Code Description Comment
A22.1 Pulmonary anthrax
A37.01 Whooping cough due to Bordetella pertussis with pneumonia
A37.11 Whooping cough due to Bordetella parapertussis with pneumonia
A37.81 Whooping cough due to other Bordetella species with pneumonia
A37.91 Whooping cough, unspecified species with pneumonia
A48.1 Legionnaires' disease
B25.0 Cytomegaloviral pneumonitis
B44.0 Invasive pulmonary aspergillosis
B77.81 Ascariasis pneumonia
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C78.00 Secondary malignant
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
14
ICD-10 Code Description Comment
D02.20 Carcinoma in situ of unspecified bronchus and lung
D02.21 Carcinoma in situ of right bronchus and lung
D02.22 Carcinoma in situ of left bronchus and lung
D14.30 Benign neoplasm of unspecified bronchus and lung
D14.31 Benign neoplasm of right bronchus and lung
D14.32 Benign neoplasm of left bronchus and lung
D56.4 Hereditary persistence of fetal hemoglobin [HPFH]
D56.8 Other thalassemias
D57.1 Sickle-cell disease without crisis
D57.20 Sickle-cell/Hb-C disease without crisis
D57.20 Sickle-cell/Hb-C disease without crisis
D57.211 Sickle-cell/Hb-C disease with acute chest syndrome
D57.212 Sickle-cell/Hb-C disease with splenic sequestration
D57.219 Sickle-cell/Hb-C disease with crisis, unspecified
D57.40 Sickle-cell thalassemia without crisis
D57.411 Sickle-cell thalassemia with acute chest syndrome
D57.412 Sickle-cell thalassemia with splenic sequestration
D57.419 Sickle-cell thalassemia with crisis, unspecified
D57.80 Other sickle-cell disorders without crisis
D57.811 Other sickle-cell disorders with acute chest syndrome
D57.812 Other sickle-cell disorders with splenic sequestration
D57.819 Other sickle-cell disorders with crisis, unspecified
D58.1 Hereditary elliptocytosis
D58.2 Other hemoglobinopathies
D75.0 Familial erythrocytosis
D75.1 Secondary polycythemia
E84.0 Cystic fibrosis with pulmonary manifestations
E84.8 Cystic fibrosis with other manifestations
E84.9 Cystic fibrosis, unspecified
G44.001 Cluster headache syndrome, unspecified, intractable
G44.009 Cluster headache syndrome, unspecified, not intractable
G44.011 Episodic cluster headache, intractable
G44.019 Episodic cluster headache, not intractable
G44.021 Chronic cluster headache, intractable
G44.029 Chronic cluster headache, not intractable
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I27.0 Primary pulmonary hypertension
I27.1 Kyphoscoliotic heart disease
I27.2 Other secondary pulmonary hypertension
I27.82 Chronic pulmonary embolism
I27.89 Other specified pulmonary heart diseases
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
15
ICD-10 Code Description Comment
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40
Unspecified combined systolic (congestive) and diastolic (congestive) heart
failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43
Acute on chronic combined systolic (congestive) and diastolic (congestive)
heart failure
I50.9 Heart failure, unspecified
J05.0 Acute obstructive laryngitis [croup]
J12.0 Adenoviral pneumonia
J12.1 Respiratory syncytial virus pneumonia
J12.2 Parainfluenza virus pneumonia
J12.3 Human metapneumovirus pneumonia
J12.81 Pneumonia due to SARS-associated coronavirus
J12.89 Other viral pneumonia
J12.9 Viral pneumonia, unspecified
J13 Pneumonia due to Streptococcus pneumonia
J14 Pneumonia due to Hemophilus influenza
J15.0 Pneumonia due to Klebsiella pneumonia
J15.1 Pneumonia due to Pseudomonas
J15.20 Pneumonia due to staphylococcus, unspecified
J15.211 Pneumonia due to Methicillin susceptible Staphylococcus aureus
J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
J15.29 Pneumonia due to other staphylococcus
J15.3 Pneumonia due to streptococcus, group B
J15.4 Pneumonia due to other streptococci
J15.5 Pneumonia due to Escherichia coli
J15.6 Pneumonia due to other aerobic Gram-negative bacteria
J15.7 Pneumonia due to Mycoplasma pneumoniae
J15.8 Pneumonia due to other specified bacteria
J15.9 Unspecified bacterial pneumonia
J16.0 Chlamydial pneumonia
J16.8 Pneumonia due to other specified infectious organisms
J17 Pneumonia in diseases classified elsewhere
J18.0 Bronchopneumonia, unspecified organism
J18.1 Lobar pneumonia, unspecified organism
J18.8 Other pneumonia, unspecified organism
J18.9 Pneumonia, unspecified organism
J40 Bronchitis, not specified as acute or chronic
J41.0 Simple chronic bronchitis
J41.1 Mucopurulent chronic bronchitis
J41.8 Mixed simple and mucopurulent chronic bronchitis
16
ICD-10 Code Description Comment
J42 Unspecified chronic bronchiti
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
J45.20 Mild intermittent asthma, uncomplicated
J45.21 Mild intermittent asthma with (acute) exacerbation
J45.22 Mild intermittent asthma with status asthmaticus
J45.30 Mild persistent asthma, uncomplicated
J45.31 Mild persistent asthma with (acute) exacerbation
J45.32 Mild persistent asthma with status asthmaticus
J45.40 Moderate persistent asthma, uncomplicated
J45.41 Moderate persistent asthma with (acute) exacerbation
J45.42 Moderate persistent asthma with status asthmaticus
J45.50 Severe persistent asthma, uncomplicated
J45.51 Severe persistent asthma with (acute) exacerbation
J45.52 Severe persistent asthma with status asthmaticus
J45.901 Unspecified asthma with (acute) exacerbation
J45.902 Unspecified asthma with status asthmaticus
J45.909 Unspecified asthma, uncomplicated
J45.990 Exercise induced bronchospasm
J45.991 Cough variant asthma
J45.998 Other asthma
J47.0 Bronchiectasis with acute lower respiratory infection
J47.1 Bronchiectasis with (acute) exacerbation
J47.9 Bronchiectasis, uncomplicated
J84.10 Pulmonary fibrosis, unspecified
J84.17
Other interstitial pulmonary diseases with fibrosis in diseases classified
elsewhere
J84.89 Other specified interstitial pulmonary diseases
P27.0 Wilson-Mikity syndrome
P27.1 Bronchopulmonary dysplasia originating in the perinatal period
P27.8 Other chronic respiratory diseases originating in the perinatal period
P27.9 Unspecified chronic respiratory disease originating in the perinatal period
P29.3 Persistent fetal circulation
Q33.4 Congenital bronchiectasis
Z99.81 Dependence on supplemental oxygen
HCPCS
Level II Code Description Comment
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.
17
HCPCS
Level II Code Description Comment
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 liquid
oxygen containers, includes portable containers, regulator, flowmeter,
humidifier, cannula or mask and tubing, with or without supply reservoir and
content gauge.
E0434
Portable liquid oxygen system, rental; includes portable container, supply
reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or
mask, and tubing.
E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator,
flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0440
Stationary liquid oxygen system, purchase; includes use of reservoir, contents
indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and
tubing.
E0441
Oxygen contents, gaseous (for use with owned gaseous stationary systems or
when both a stationary and portable gaseous system are owned), 1 month's
supply = 1 unit.
E0442
Oxygen contents, liquid (for use with owned liquid stationary systems or when
both a stationary and portable liquid system are owned), 1 month's supply = 1
unit.
E0443
Portable oxygen contents, gaseous (for use only with portable gaseous
systems when no stationary gas or liquid system is used), 1 month's supply =
1 unit.
E0444 Portable oxygen contents, liquid (for use only with portable liquid systems
when no stationary gas or liquid system is used), 1 month's supply = 1 unit.
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 85 percent or
greater oxygen concentration at the prescribed flow rate, each.
E1392 Portable oxygen concentrator, rental
E1405 Oxygen and water vapor enriching system with heated delivery.
E1406 Oxygen and water vapor enriching system without heated delivery.
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.
S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot.
S8121 Oxygen contents, liquid, 1 unit equals 1 pound.