Oxygen

POLICY NUMBER

L.1.01.403

DESCRIPTION

Oxygen and Oxygen accessories are considered to be Durable Medical Equipment (DME). DME are items which are used to serve a medical purpose, can withstand repeated use, are generally not useful to a person in the absence of illness, injury, or disease, and are appropriate for use in the patient’s home. Construction costs to the Member’s residence to accompany the equipment are not considered DME.

Coverage for Oxygen Therapy is subject to the terms, conditions and limitations of the DME benefit within the Member’s specific benefit plan language.

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.

Indications for Obstructive Sleep Apnea (OSA) and related equipment for OSA are addressed in the  Sleep Disorders policy.

Indications for  Hyperbaric Oxygen Therapy  are addressed in a separate policy.

Indications for Devices used to treat Respiratory Disorders (not including Cystic Fibrosis) are addressed in the  Respiratory Devices policy.

Indications for Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions are addressed in a separate policy.

Indications for  Inhaled Nitric Oxide are addressed in a separate policy.

Indications for the  Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders are addressed in a separate policy.

Indications for  Home Cardiorespiratory Monitoring are addressed in a separate policy.

Indications for  Respiratory Syncytial Virus (RSV) Prevention  are addressed in a separate policy.

POLICY

1. Clinical Indications for medical necessity:

   1. Oxygen therapy is considered medically necessary for:

      1. Severe lung disease in a patient as defined by:

         • A resting arterial oxygen partial pressure (PaO2) below 55mm Hg or 60 mmHg in the presence of heart failure, or

         • An O2 saturation less than 90 percent, or

         • Symptoms associated with oxygen deprivation, such as impairment of cognitive processes, restlessness, or insomnia

      2. Cluster headaches when other treatment fails, as defined by:

         • Severe unilateral, orbital, supraorbital, or temporal pain lasting at least 15 minutes, and

         • At least one of the following symptoms on the headache side:

           • Conjunctival injection, or

           • Lacrimation, or

           • Nasal congestion, or

           • Rhinorrhea, or

           • Forehead and facial sweating, or

           • Miosis, or

           • Ptosis, or

           • Eyelid edema

   2. Oxygen and oxygen supplies are covered for appropriately selected patients, as described above, only when oxygen is prescribed by a physician within 30 days of the documentation, and the prescription specifies:

      • A diagnosis of the disease requiring use of oxygen

      • Oxygen concentration and flow rate

      • Frequency of use (if an intermittent or leave in oxygen therapy, order must include time limits and specific indications for initiating and terminating therapy)

      • Method of delivery

      • Duration of use (if prescribed on an indefinite basis, the care will be periodically reviewed to determine whether a medical need continues to exist)

   3. Patients receiving long-term oxygen therapy will be periodically re-evaluated to assess whether hypoxemia persists.

2. Clinical Indications that are not medically necessary:

   1. 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

3. Equipment:

   1. Oxygen Delivery Systems include:

      • Stationary compressed gaseous oxygen systems

      • Portable gaseous oxygen systems

      • Stationary liquid oxygen systems

      • Portable liquid oxygen systems

      • One month supply oxygen contents, gaseous or liquid, for stationary or portable system

      • Oxygen concentrator, single or dual delivery port

      • Portable oxygen concentrator

      • Oxygen and water vapor enriching systems with or without heated delivery

   2. Accessories for Oxygen Therapy are considered an integral part of the rental or purchase allowance for the oxygen delivery system. Accessories include (but not limited to):

      • Nasal cannula

      • Mask

      • Tubing

      • Tent

      • Humidifier

      • Nebulizer

      • Regulator

      • Flow meter

      • Maxi-mist

      • Oxygen gauge

   3. "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.

   4. 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.

   5. 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.

   6. 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

4. Repair or Replacement:

   1. Benefits will be provided for repair, adjustment or replacement of the purchased equipment or components only within a reasonable time period of purchase subject to the lifetime expectancy of the equipment

   2. No Benefits will be provided during rental for repair, adjustment, or replacement of components and accessories necessary for the effective functioning and maintenance of covered equipment as this is the responsibility of the Durable Medical Equipment supplier.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

2/1988: 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, 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.

4/22/2010: Description Section updated to include standard contract DME language, and links to other medical policies with indications for oxygen, Policy Statement Section revised to include Cluster headache medical necessity criteria, clarification on the time parameter for prescription, Equipment section added with oxygen delivery systems and accessories, and Repair or Replacement section added with standard benefit contract language,  removed examples of severe lung disease, removed portable oxygen systems from oxygen accessories list, removed verbiage "Portable oxygen systems are considered medically necessary only if the patient ambulates on a regular basis, Sources Section updated to add CMS as a reference, Coding Section revised with verbiage to Covered Codes Section, CPT4 codes 94660, 94662, 99183 removed from Covered Codes Table, removed ICD9 procedure codes 93.91, 93.95 and 93.99 from Covered Codes Table, added ICD-9 diagnosis codes: 346.23, 493.22, 495.0 - 495.9, 770.88, 786.9 and V46.2 to Covered Codes Table, Removed HCPCS codes A4611 - A4614, A7030, A7034, A7035, A7036, A7037, A7038, A7039, A7027, A7028, A7029, E0651, E0562, E0565, E0570, E0571, E0572, E0574, E0575, E0585, K0553, K0554, K0555 from Covered Codes Table, Added HCPCS codes A4608, A7520, A7521, A7522, A7525, E0433, E0550, and S8121 to Covered Codes table, Added coding definitions to HCPCS codes A4615- A4623, E0424- E0580, E1353- E1406, Added HCPCS code E1354 to Non-Covered Codes Table.

08/31/2015: Code Reference section updated for ICD-10. Removed ICD-9 diagnosis code 346.2.

12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions.

05/31/2016: Policy number L.1.01.403 added.

09/29/2017: Policy links updated in policy description. Code Reference section updated to add new ICD-10 diagnosis codes I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.83, I50.84, and I50.89, effective 10/01/2017. Removed deleted HCPCS codes A7011 and E0450.

05/16/2018: Updated medical policy links in policy description.

12/19/2018: Code Reference section updated to add new HCPCS code E0447, effective 01/01/2019.

11/08/2022: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

05/02/2023: Policy reviewed; no changes.

09/29/2023: Code Reference section updated to add new ICD-10 diagnosis codes J44.81, J44.89, J4A.0, J4A.8, and J4A.9, effective 10/01/2023.

06/06/2024: Policy reviewed. Policy links updated. Policy statements unchanged.

08/04/2025: Policy reviewed; no changes.

SOURCE(S)

1. 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.

2. Blue Cross Blue Shield Association policy # 1.01.12

3. Centers for Medicare and Medicaid Services

4. Hayes Medical Technology Directory

5. Medicare Guidelines on Oxygen

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Not Medically Necessary Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.