Home oxygen therapy is most commonly used to treat chronic, stable medical
conditions that cause significant hypoxemia, such as severe lung disease (e.g.,
chronic obstructive pulmonary disease [COPD], interstitial fibrosis, cystic
fibrosis, pulmonary neoplasm), pulmonary hypertension, and congestive heart
failure related to cor pulmonale. Appropriate evidence of significant hypoxemia
includes arterial blood gas studies, pulse oximetry, and certain clinical
signs, such as elevated pulmonary artery pressure, dependent edema, and
polycythemia vera.
Home oxygen therapy may be delivered via nasal cannula, face mask, or
transtracheal catheter. Supply sources include a stationary or portable
compressed gas tank, stationary or portable liquid oxygen tank, or stationary
oxygen concentrator.
Our current Medical Policy #05.00.58e: Home Oxygen Therapy will be updated as
outlined below, and revised Medical Policy
#05.0058f will become effective April 1, 2013.
The following policy criteria have been revised:
Group 1 Criteria
Current policy
Revised policy (effective April 1, 2013)
The individual demonstrates a decrease in arterial PO2 more than 10 mmHg or a
decrease in arterial oxygen saturation more than 5 percent for at least five*
minutes during sleep associated with symptoms or signs reasonably attributable
to hypoxemia (e.g., cor pulmonale, P-pulmonale on electrocardiogram [P-wave
greater than 3 mm in standard leads II, III, or AVF], documented pulmonary
hypertension, polycythemia vera).
The individual demonstrates a decrease in arterial PO2 greater than 10 mmHg or
a decrease in arterial oxygen saturation greater than 5 percent from baseline
for at least five* minutes during sleep that is associated with any of the
following signs and symptoms attributable to hypoxemia:
Nocturnal restlessness
Insomnia
Cor pulmonale
"P" pulmonale on electrocardiogram (EKG)
Documented pulmonary hypertension
Erythrocytosis
*For all the sleep oximetry criteria described above, the five minutes do not
have to be continuous.
Prescription renewal
Current policy
Revised policy (effective April 1, 2013)
A revised prescription for home oxygen therapy is required in any of the
following situations:
When the prescribed maximum flow rate changes from one of the following
categories to another:
Less than 1 LPM
1 – 4 LPM
Greater than 4 LPM
If the change is from less than 4 LPM to greater than 4 LPM, a repeat blood gas
study with the individual on 4 LPM must be performed.
If the physician specified less than lifetime length of need on the most recent
CMN, and this length of need has expired.
When a portable oxygen system is added subsequent to the initial certification
of a stationary system.
When a stationary system is added subsequent to the initial certification of a
portable system.
When there is a new treating physician but the oxygen order is the same.
A change in a DME provider who does not have the prior prescription.
A revised prescription for home oxygen therapy is required
in any of the following situations:
When the prescribed maximum flow rate changes from one of the following
categories to another:
Less than 1 LPM
1 – 4 LPM
Greater than 4 LPM
If the change is from less than 4 LPM to greater than 4 LPM, a repeat blood gas
study with the individual on 4 LPM must be performed.
A blood gas study must be the most recent study obtained within 30 days prior
to the initial date.
If the physician specified less than lifetime length of need on the most recent
CMN, and this length of need has expired. A blood gas study must be the most
recent study obtained within 30 days prior to the initial date.
When a portable oxygen system is added subsequent to the initial certification
of a stationary system. There is no requirement for a repeat blood gas study
unless the initial qualifying study was performed during sleep, in which case a
repeat blood gas study must be performed while the beneficiary is at rest
(awake) or during exercise within 30 days prior to the revised date.
When a stationary system is added subsequent to the initial certification of a
portable system.
When there is a new treating physician but the oxygen order is the same.
A change in a DME provider who does not have the prior prescription.
The following policy criteria have been added:
Recertification in other scenarios:
For replacement equipment, repeat testing is not required. Enter the most
recent qualifying value and test date. This test does not have to be within 30
days prior to the initial date. It can be the test reported on the most recent
certification.
There is no requirement for a physician visit related to the certification for
replacement of equipment.
Please refer to the
Medical Policy
section of our IBC website to view our medical policies. For questions or
additional information related to our home oxygen therapy policy, please
contact your Network Coordinator.