· Decrease shortness of breath and fatigue
· Improve sleep in some people who have sleep-related breathing disorders
· Increase the lifespan of some people who have COPD
· Prevent heart failure in people with severe lung disease

· compressed gas,
· liquid, or
· concentrated form taken from the air.

• at rest (awake);
• with ambulation;
• with sleep.

Arterial blood gas (ABG)—arterial blood gases are a measurement of how much oxygen and carbon dioxide are in the blood as well as the acidity (pH). Usually, blood is taken from an artery such as the radial artery in the wrist, the femoral artery in the groin or the brachial artery in the arm.

Carbon dioxide (CO₂) narcosis-- a condition of confusion, tremors, convulsions, and possible coma that may occur if blood levels of carbon dioxide increase to 70 mm Hg or higher. Individuals with chronic obstructive pulmonary disease can have CO₂ narcosis without these symptoms because they develop a tolerance to elevated CO₂. When ventilation is sufficient to maintain a normal oxygen partial pressure in the arteries, the carbon dioxide partial pressure is generally near 40 mm Hg.

Cluster headache-- a type of headache. It is one-sided head pain that may involve tearing of the eyes and a stuffy nose. Attacks occur regularly for 1 week to 1 year. The attacks are separated by pain-free periods that last at least 1 month or longer.

Dyspnea-– shortness of breath.

Hypoxia-— low levels of oxygen in the blood.

Oxygen concentrator-- a machine that plugs in to an electrical outlet and takes room air, passes it through the filtering system in the machine and converts it to more pure oxygen. Room air is circulated through the machine filtering system and changes from regular room air (21% oxygen) to approximately 95% oxygen.

Pulse oximetry-- a procedure used to measure the oxygen level (or oxygen saturation) in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

A. Home oxygen therapy is considered medically necessary when all of the following conditions are met:

1. The treating physician has prescribed oxygen therapy for a member who has a severe lung disease or hypoxia-related symptoms that are known to clinically improve with oxygen therapy; and
2. The member's arterial blood gas study or pulse oximetry meets either criteria Group I or Group II; and

3. The qualifying blood gas study or pulse oximetry was obtained under either of the following conditions:
a. If the qualifying arterial blood gas study or pulse oximetry is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
b. If the qualifying arterial blood gas study or pulse oximetry is not performed during an inpatient hospital stay, the reported test must be performed while the member is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease.

For purposes of this policy, either an arterial blood gas or pulse oximetry* result measuring oxygen saturation is acceptable.

*Pulse oximetry readings are accurate to +/-4%.

The member may require oxygen following a hospital stay for acute diagnoses such as:
• Pneumonia
• Pulmonary Embolism
• Bronchitis

Lab values must be documented to support the medical necessity for short term oxygen use after discharge from the hospital.

The need for oxygen after discharge from the hospital may resolve with limited or short term use, (i.e., 30 days). Documentation to support the medical necessity for ongoing oxygen therapy beyond thirty (30) days post-discharge should include documentation pertaining to oxygen saturation. (Also see policy statement G below.)

Pulse oximetry or arterial blood gas studies are not required to determine medical necessity for treatment of cluster headache with oxygen.

Treatment of acute attacks of cluster headache with inhalation of 100% oxygen via face mask with a flow rate of at least 7 L/min over 15 min alone or along with the administration of triptans is considered medically necessary.

Oxygen use with PAP devices requires the following be met for initial set up:

Medical necessity for both the oxygen and oxygen equipment and positive airway presssure (PAP) devices for the treatment of obstructive sleep apnea must be met. (Please refer to a separate policy on 'Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome' Policy #002 in the Medicine Section) and,

To determine the medical necessity for oxygen therapy for a member with obstructive sleep apnea, the member must be in a “chronic stable state” (not during a period of an acute illness or an exacerbation of their underlying disease) and meets either of the following:

• A qualifying oxygen saturation test must be done during a titration polysomnographic study (either split night or stand-alone).
The titration polysomnography (PSG) is one in which all of the following criteria are met:
1. The titration is conducted over a minimum of two (2) hours; and
2. During titration:
a. the AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
b. if the initial AHI/RDI was less than an average of ten (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
3. Nighttime oximetry conducted for the purpose for oxygen reimbursement qualification is performed after optimal PAP settings have been determined and the member is using the PAP device at those settings; and
4. The nighttime oximetry conducted during the PSG demonstrates an oxygen saturation ≤ 88% for 5 minutes total, measured on pulse oximetry (which need not be continuous).
OR
• A qualifying oxygen saturation test may occur after the member has been prescribed PAP therapy and has ongoing hypoxia.
  • The nighttime oximetry conducted while on optimal PAP therapy demonstrates an oxygen saturation <88% for 5 minutes total, measured on pulse oximetry, which need not be continuous.
  • The use of home oxygen therapy as the sole treatment for sleep apnea, including obstructive sleep apnea (OSA) is not considered medically necessary.

Terminal care is defined as the management of members during the last few days or weeks or even months of life.

When oxygen for terminal care is a covered benefit under the member's contract, the member does not need to demonstrate hypoxemia or oxygen saturation.

The peer-reviewed medical literature does not support routine use of oxygen without evidence of desaturation (e.g. Alzheimer’s disease, cancer, etc.).

Ongoing use of oxygen therapy is considered medically necessary when:
• the member's oxygen saturation level, (measured either by pulse oximetry or arterial blood gas) is within the criteria described in either Group I or Group II (see above) values, and
• documentation in the member's clinical record indicates adherence to the prescribed oxygen therapy.

Retesting for oxygen re-qualification can be done by:
• Qualified provider/supplier of laboratory services, or
• DME provider of oxygen and oxygen equipment.

Short Term-Acute Diagnoses (e.g. pneumonia, bronchitis, etc.):
• If continued oxygen therapy is ordered after 3 months of initial therapy, a repeat arterial blood gas study or pulse oximetry reading is considered medically necessary to evaluate if the member continues to meet the criteria in either Group I or Group II.

Long Term-Chronic Diagnoses (e.g. COPD, CHF, etc.):
• A repeat arterial blood gas study or pulse oximetry reading is considered medically necessary 12 months after oxygen therapy is initiated and annually thereafter.
• Oxygen in conjunction with PAP therapy:
  Continued oxygen therapy with PAP, requires the member be tested annually using overnight pulse oximetry on PAP therapy alone and without supplemental oxygen bleed into PAP.

A portable oxygen system is considered medically necessary when the member is mobile within the home and the qualifying blood gas study/oxygen saturation was performed while at rest (awake) or during exercise. If the only qualifying blood gas study/oxygen saturation was performed during sleep, portable oxygen is not considered medically necessary.

Use of portable oxygen systems is defined as:
1. Non-portable oxygen concentrators (E1390) and portable oxygen canisters
2. Portable oxygen concentrators (E1392) that are capable of delivering 85% or greater oxygen concentration can operate either on AC/DC power. The unit must also be capable of functioning as a stationary concentrator, operating 24 hours per day, 7 days per week

Portable oxygen systems (i.e., tanks or concentrators) used with stationary oxygen systems are indicated when the above guidelines for home oxygen use and portability are met.

[INFORMATIONAL NOTE: Special Circumstances: Airline Travel - members travelling should verify if their portable oxygen system is approved for use with their airline carrier.]

FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Home Oxygen Therapy
Oxygen Therapy at Home
Oxygen Concentrators
Concentrators, Oxygen
Portable Oxygen Systems

References:
1. American Lung Association, Supplemental Oxygen. Accessed 2/20/2015 at URL address: http://www.lung.org/lung-disease/copd/living-with-copd/supplemental-oxygen.html

2. National Heart, Lung and Blood Institute. How Does Oxygen Therapy Work? Accessed 2/20/2015 at URL address: http://www.nhlbi.nih.gov/health/health-topics/topics/oxt/howdoes

3. Agency for Healthcare Research and Quality. National Guideline Clearinghouse. Cluster headache and other trigemino-autonomic cephalgias. National Institute for Health and Clinical Excellence (NICE)’s guideline on “Diagnosis and management of headaches in young people and adults” (2012). Accessed 2/20/2015 at URL address: http://www.guideline.gov/content.aspx?id=34898

4. Pierson, D.J. National Institutes of Health. Pulse oximetry versus arterial blood gas specimens in long-term oxygen therapy. Lung. 1990;168 Suppl:782-8. Accessed 2/20/20115 at URL address: http://www.ncbi.nlm.nih.gov/pubmed/2117192

5. National Lung Health Education Program. Home Oxygen Options. Accessed 2/20/2015 at URL address: http://www.nlhep.org/Style%20Library/PageSets/PageSet-Guide_to_Prescribing/home-oxygen-options-4.htm

6. Beck, Ellen, MD, William J. Sieber, PhD, and Raul Trejo, MD, University of California, San Diego, La Jolla, California. Am Fam Physician. 2005 Feb 15;71(4):717-724. American Academy of Family Physicians. Management of Cluster Headache. Accessed 2/20/2015 at URL address: http://www.aafp.org/afp/2005/0215/p717.html
7. National Institute for Health and Clinical Excellence (NICE)’s guideline on “Diagnosis and management of headaches in young people and adults” (2012) Accessed 2/20/2015 at URL address: http://www.guideline.gov/content.aspx?id=34898

8. Tanneberger, S. , I. Malavasi, P. Mariano, F. Pannuti and E. Strocchi. Planning palliative or terminal care: the dilemma of doctors’ prognoses in terminally ill cancer patients Annals of Oncology, (2002) 13 (8): 1320-1322. Oxford Journals. Accessed on 2/20/2015 at URL address: http://annonc.oxfordjournals.org/content/13/8/1320.1.long

9. Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) for Home Use of Oxygen (240.2) 10/27/1993. Accessed 2/20/2015.

10. Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination for Oxygen and Oxygen Equipment LCD 11446. 1/1/2014. Accessed 2/20/2014.

11. Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination for Oxygen and Oxygen Equipment LCD 11468. 1/1/2014 Accessed 2/20/2014.

12. Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2009;5(3):263-276. Available at: http://jcsm.aasm.org/viewabstract.aspx?pid=27497

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

A4575
A4606
A4608
A4615
A4616
A4617
A4619
A4620
A9900
E0424
E0425
E0430
E0433
E0434
E0435
E0439
E0440
E0441
E0442
E0443
E0444
E0445
E0446
E0455
E0555
E0580
E1352
E1353
E1354
E1355
E1356
E1357
E1358
E1390
E1391
E1392
E1405
E1406
K0738