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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.

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:

• 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%).

Oxygen therapy is considered medically necessary for 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, impairment of cognitive processes, restlessness, or insomnia 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.

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:

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 prescribed on an indefinite basis, the care will be periodically reviewed to determine whether a medical need continues to exist).

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:

• Portable oxygen systems;
• Mask or nasal cannula;
• Maxi-mist;
• Nebulizer;
• Oxygen gauge;
• Oxygen humidifier;
• Oxygen tubing.

The following components of oxygen therapy are considered not medically necessary:

• Oxygen and oxygen supplies in facilities that are expected to supply such items;
• Setup or installation of respiratory support systems;
• Preset regulators used with portable oxygen systems;
• Regulators which permit a flow rate greater than 8 liters per minute as these units are not appropriate for home use;
• An excessive number of spare tanks, as they are considered a convenience item only;
• A prescription for oxygen for use as needed (PRN);
• Portable oxygen systems are not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep (added 8-23-2001).

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.

None

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.

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, 5^th 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

Medicare Guidelines on Oxygen

Hayes Medical Technology Directory

Blue Cross Blue Shield Association policy # 1.01.12

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