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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.
POLICYOxygen therapy is considered medically necessary for:
Severe lung disease, defined as either: a resting arterial oxygen partial pressure (Pa02) below 55mm Hg or 60 mm Hg in the presence of heart failure, 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:
Oxygen therapy is considered medically necessary for cluster headaches when other treatment fails.
Oxygen therapy is considered not medically necessary for the following conditions:
Oxygen and oxygen supplies are considered medically necessary for appropriately selected patients described above, only in cases when oxygen is prescribed by a physician, and the prescription specifies:
Patients receiving long-term oxygen therapy will be periodically re-evaluated to assess whether hypoxemia persists.
The following items frequently accompany the use of oxygen:
The following components of oxygen therapy are considered not medically necessary:
Charges for oxygen carts, racks, or stands are included in the suppliers' fee for use of the oxygen tank and are not covered as a separate service.
If more than one tank is required in a month, the cost of the oxygen contained in two or more tanks will be covered. Rental will be paid for the initial tank only.
"E" tanks normally do not qualify as a portable oxygen system; however, there may be instances when an "E" tank may be considered medically necessary even though the patient has a stationary tank at bedside.
Portable oxygen systems are considered medically necessary only if the patient ambulates on a regular basis.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
The rental of oxygen tanks is eligible for coverage subject to the Durable Medical Equipment Benefit in the subscriber's contract.
POLICY HISTORY2/1988: DME Manual policy
8/1998: Comprehensive revision approved by Medical Policy Advisory Committee (MPAC)
8/23/2001: "Portable oxygen systems are not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep." added
2/19/2002: Managed Care Requirements added
3/19/2002: "E" tank review on an individual basis has been deleted
5/2/2002: Type of Service and Place of Service deleted
6/23/2004: Policy reviewed, Sources updated
10/18/2005: Code Reference updated; CPT-4 82803-82810, 94650-94651, 94799, 99195 deleted; ICD-9 Procedure 38.99, "Other diseases of blood and blood-forming organs" deleted; 492.8, 493.21, 494.1 added; HCPCS: A4621, K0531, K0532 - K0534 deleted; HCPCS: A4620 was deleted as a separate listing for oxygen masks, but still remains listed with other oxygen supplies.
11/8/2005: Code Reference section updated, 5th digit added to ICD9 diagnosis code 799.02
3/9/2006: Coding updated. CPT-4/HCPCS 2006 revisions added to the policy
3/10/2006: Policy clarified, no other changes
4/5/2006: Coding Reference section updated. HCPC revisions added to policy
4/26/2006: Coding Reference section updated. HCPC revision added to policy
9/21/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
12/19/2007: Coding updated per 2008 CPT/HCPCS revisions
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
SOURCE(S)A search of the literature was completed through the MEDLINE database for the period of January 1990 through September 1996. The search strategy focused on references containing the Medical Subject Heading of Oxygen. Research was limited to English-language journals on humans.
Medicare Guidelines on Oxygen
Hayes Medical Technology Directory
Blue Cross Blue Shield Association policy # 1.01.12
CODE REFERENCEThis is not intended to be a comprehensive list of codes. Note that some codes may be variable, and coverage will be based on the clinical indication for the service.