CAM 10112

Oxygen Therapy

Category:Durable Medical Equipment   Last Reviewed:July 2019
Department(s):Medical Affairs   Next Review:July 2999
Original Date:July 1997    

Description:
Oxygen is administered by inhalation-utilizing devices that provide controlled oxygen concentrations and flow rates to the patients. Oxygen therapy should maintain adequate tissue and cell oxygenation while trying to avoid oxygen toxicity.

Monitoring of the patient’s condition takes place to assure that the patient is receiving the proper mixtures of gases, mists and aerosols.

Policy:
Oxygen and oxygen supplies are considered MEDICALLY NECESSARY for appropriately selected patients only in cases when oxygen is prescribed by a physician, and the prescription must specify:

  1. a diagnosis of the disease requiring use of oxygen
  2. oxygen concentration and flow rate
  3. frequency of use (if an intermittent or leave-in oxygen therapy, order must include time limits and specific indications for initiating and terminating therapy)
  4. method of delivery
  5. duration of use (if the oxygen is prescribed on an indefinite basis, care must be periodically reviewed to determine whether a medical need continues to exist).

Continuous Pulse Oximetry for home use is considered MEDICALLY NECESSARY durable medical equipment (DME) for members with any of the following indications:

  • When weaning the individual from home oxygen; or
  • To use as a screening test to determine if a polysomnography is indicated; or
  • To monitor individuals on a ventilator at home.

The use of home pulse oximetry is considered NOT MEDICALLY NECESSARY for all other indications, including, but not limited to, the following:

  • Asthma management; or
  • When a change in the individual's physical condition requires an adjustment in the liter flow of their home oxygen needs; or
  • To determine appropriate home oxygen liter flow for ambulation, exercise or sleep;
  • Solely to diagnose sleep apnea. 

If the medical necessity criteria for the use of oxygen is met, either liquid or gaseous oxygen are considered medically necessary; however, having both liquid and gaseous oxygen is considered NOT MEDICALLY NECESSARY. (e0442, e0443)

Policy Guidelines:
Oxygen therapy is considered medically necessary for:

  1. Severe lung disease, defined as either: a resting arterial oxygen partial pressure (PaO2) below 55 mm Hg; or an O2 saturation less than 90%; or symptoms associated with oxygen deprivation, such as impairment of cognitive processes, restlessness, or insomnia. Examples of severe lung disease include, but are not limited to:
    • Chronic obstructive pulmonary disease (COPD);
    • Pulmonary fibrosis;
    • Cystic fibrosis;
    • Bronchiectasis;
    • Recurring congestive heart failure due to chronic cor pulmonale
    • Chronic lung disease complicated by erythrocytosis (hematocrit >56%).
  2. Cluster headaches when other treatment fails.
    Oxygen therapy is considered NOT MEDICALLY NECESSARY for the following conditions:
    • Angina pectoris in the absence of hypoxemia;
    • Breathlessness without evidence of hypoxemia;
    • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities;
    • Terminal illnesses that do not affect the lungs.

Portable oxygen systems are considered MEDICALLY NECESSARY only if the patient ambulates on a regular basis.

Coding Section

Codes Number Description
CPT 82803-82810 Blood gas code range
  94660 Continuous positive airway pressure (CPAP) ventilation, initiation and management
  94662 Continuous negative pressure (CNP) ventilation, initiation and management
  94799 Unlisted pulmonary service or procedure
ICD-9 Procedure  93.96 Oxygen therapy
ICD-9 Diagnosis 289.0 Other diseases of blood and blood-forming organs (polycythemia, secondary. Includes erythrocytosis) 
  346.2 Variants of migraine (includes cluster headache) 
  416.9 Chronic pulmonary heart disease, unspecified (includes cor pulmonale, chronic) 
  428.0 Congestive heart failure 
  780.52 Restlessness
  799.2 Insomnia 
HCPCS  A4606-A4629  Supplies for oxygen code range
  E0424-E0484  Oxygen and related respiratory equipment injection, Sargramostim (GM-CSF), 250 mcg, code range 
  E0500-E0590 

IPPB machines and humidifiers/nebulizers for use with IPPB equipment 

  E1353-E1406  Additional oxygen-related equipment code range 
ICD-10-PCS (effective 10/01/15)  3E0F7GC  Introduction of Other Therapeutic Substance into Respiratory Tract, Via Natural or Artificial Opening 
ICD-10-CM (effective 10/01/15)  D75.1  Secondary polycythemia 
  G43 Migraine
  I27.81 Cor pulmonale (chronic)
  I27.9 Pulmonary heart disease, unspecified
  I50.9 Heart failure, unspecified
  G47.00 Insomnia, unspecified
Type of Service Medical Supply  
Place of Service Outpatient/Home  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

07/08/2019 

Annual review, no change to policy intent.

07/30/2018 

Annual review, no change to policy intent. 

02/18/2018 

Interim review to add statement regarding the lack of medical necessity to have both liquid and gaseous oxygen. NO other changes made. 

07/31/2017 

Annual review, no change to policy intent. 

07/06/2016 

Annual review, no change to policy intent.  

10/13/2015 

Adding the following language: Continuous Pulse Oximetry for home use is considered MEDICALLY NECESSARY durable medical equipment (DME) for members with any of the following indications: 

07/06/2015 

Annual review, no change to policy intent. Added coding. 

07/10/2014

Annual review, no changes made.


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