Oxygen Therapy - Medical Necessity Criteria
Criteria for documenting medical necessity of oxygen therapy, oxygen systems, or oxygen concentrators as durable medical equipment.
Contents:
- When is oxygen therapy medically necessary?
- Medical necessity criteria for oxygen therapy
- What are the diseases or symptoms that might be expected to improve with oxygen therapy?
- What are the signs and symptoms that are reasonably attributable to hypoxemia?
- When is oxygen therapy not considered medically necessary?
- Health plan criteria for oxygen therapy
When is oxygen therapy medically necessary?
Oxygen therapy is generally considered medically necessary for patients who have a medical condition that is expected to improve with oxygen therapy, with documented hypoxemia, when other treatments have been tried (or considered) and found to be ineffective.
Medical necessity criteria for oxygen therapy
Oxygen systems for oxygen therapy, including oxygen concentrators, are considered medically necessary in patients who have diseases/symptoms that might be expected to improve with oxygen therapy* AND meet either of the following criteria:
- Criteria at rest. When the patient has either:
- An arterial PO2 at or below 55 mm Hg at rest, or
- An arterial oxygen saturation at or below 88% at rest.
- Criteria during sleep. When the patient does not meet the criteria at rest but has either:
- An arterial PO2 at or below 55 mm Hg during sleep, or
- An arterial oxygen saturation at or below 88% during sleep, or
- Signs and symptoms that can be reasonably attributed to hypoxemia** with either:
- A decrease in arterial PO2 more than 10 mm Hg from baseline for at least 5 minutes during sleep, or
- A decrease in arterial oxygen saturation more than 5% from baseline for at least 5 minutes during sleep.
- Criteria during exercise. When the patient does not meet the criteria at rest but has either:
- An arterial PO2 at or below 55 mm Hg during exercise, or
- An arterial oxygen saturation at or below 88% during exercise.
- A patient who has an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89% or lower either at rest, at sleep, or during exercise, if any of the following is also present:
- Erythrocythemia with a hematocrit greater than 56%
- Pulmonary hypertension or cor pulmonale
- Dependent edema suggestive of congestive heart failure
Additionally, alternative treatment measures must have been tried or considered and deemed to be clinically ineffective.
When both arterial blood gas and oximetry studies were used to document hypoxemia and the results of the two methods are conflicting, the results of the arterial blood gas study will be given preference.
The oxygen tests must be conducted by a qualified professional as determined by the patient’s health plan.
* What are the diseases or symptoms that might be expected to improve with oxygen therapy?
- Asthma (usually requires only short-term oxygen therapy)
- Bronchiectasis
- Bronchitis (usually requires only short-term oxygen therapy)
- Broncho-pulmonary dysplasia (BPD) in a pediatric patient
- Chronic obstructive pulmonary disease (COPD)
- Cluster headaches
- Congestive heart failure that is recurring and due to chronic cor pulmonale
- Croup (usually requires only short-term oxygen therapy)
- Cystic fibrosis
- Diffuse interstitial lung disease
- Erythrocytosis (hematocrit greater than 55%)
- Hemoglobinopathies
- Pneumonia (usually requires only short-term oxygen therapy)
- Pulmonary hypertension
- Pulmonary neoplasm that has become widespread
** What are the signs and symptoms that are reasonably attributable to hypoxemia?
They include but are not limited to:
- impairment of cognitive processes
- nocturnal restlessness or insomnia
- cor pulmonale
- “P” pulmonale on electrocardiogram
- documented pulmonary hypertension and erythrocytosis
When is oxygen therapy NOT considered medically necessary?
Oxygen is generally not considered medically necessary for the following non-covered indications:
- Angina pectoris when there is no hypoxemia
- Breathlessness or dyspnea when there is no evidence of hypoxemia or cor pulmonale
- Peripheral vascular disease with desaturation in the extremities but no systemic hypoxemia (because there is no evidence that increased oxygen pressure improves oxygenation of tissues with impaired circulation)
- Terminal illnesses that do not affect the patient’s ability to breathe
Health plan criteria for oxygen therapy
- Aetna Clinical Policy on Oxygen
- Amerigroup Clinical UM Guideline on Home Oxygen Therapy
- Blue Cross Blue Shield of North Dakota Policy on Oxygen
- Health Net Clinical Policy on Oxygen Use and Concentrators
- Medicare National Coverage Determination (NCD) on Home Use of Oxygen
- Premera Blue Cross Medical Policy on Home Oxygen Therapy