Not logged in - Login / Register

LCD - Oxygen

Coverage Summary

To meet Insurance requirements, (1-5) listed below must be met. Refer to 'Coverage Details' below for specific criteria.

  1. Written Order Prior to Delivery
  2. Documentation that the patient has a severe lung disease or hypoxia related symptoms that might be expected to improve with long term oxygen therapy.
  3. Qualifying O2 SATs (refer to Coverage Detail below regarding specific O2 SAT test requirements)
  4. Documentation of alternative measures that have been tried, failed, or considered and ruled out.
  5. Portable oxygen is covered if the patient is documented to be mobile within the home and have qualifying O2 SATs (at rest/awake or during exercise).

NOTE:

Exacerbation is an Acute status which must be resolved at the time of discharge.

Pneumonia must be documented as no longer a contributing factor to patient desaturations or been resolved.

For oxygen to be covered under a diagnosis of Congestive Heart Failure, it must be documented that patient has Recurring Congestive Heart Failure with Cor Pulmonale as required by insurance coverage guidelines.

Order Requirements

  1. Patient Name
  2. Detailed description of specific equipment being ordered (Oxygen Concentrator, Regulator, Conserving Device)
  3. Quantity to be dispensed
  4. Dosage or concentration of the drug
  5. Route of Administration
  6. Frequency of administration
  7. Infusion rate / Duration of infusion
  8. Number of refills
  9. Ordering Physician’s NPI
  10. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  11. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  12. Start date of the order – if different than physician signature date.

Coverage Detail

1) The treating physician has determined that the patient has a sever lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy.

Conditions for Which Oxygen Therapy May Be Covered (not an all inclusive list):

  • A severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or
  • Hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. Examples of these symptoms and findings are pulmonary hypertension, recurring congestive heart failure due to chronic cor pulmonale, erythrocytosis, impairment of the cognitive process, nocturnal restlessness, and morning headache.

Conditions for Which Oxygen Therapy Is Not Covered (not an all inclusive list):

  • Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood, and there are other preferred treatments;
  • Breathlessness without cor pulmonale or evidence of hypoxemia. Although intermittent oxygen use is sometimes prescribed to relieve this condition, it is potentially harmful and psychologically addicting;
  • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities. There is no evidence that increased PO2 improves the oxygenation of tissues with impaired circulation;
    1. Diagnosis of OSA alone
    2. Diagnosis of pneumonia

If there is a co-existing chronic pulmonary condition, there must be documentation that the pneumonia has been sufficiently treated and is not contributing to hypoxia related symptoms. Terminal illnesses that do not affect the lungs.

2) The patient has had a blood gas study that meets one of the following blood gas study qualifications:

NOTE: Facility discharging patient’s must have a blood gas study within (2) days of discharge. Blood gas study performed must be recorded in the patient’s medical record that is legibly signed and dated by the physician.

Blood Gas Study Qualifications – Group I:

  • Qualifying at rest (while awake but sitting or lying down), an arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake) or;

  • Qualifying with exercise (3) tests required and must be completed in one session:

An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.

    1. Blood gas study performed at rest without oxygen on room air
    2. Blood gas study performed during exercise without oxygen on room air
    3. Blood gas study performed during exercise with oxygen applied that demonstrates improvement of hypoxia.

NOTE: Oximetry obtained after exercise while resting, sometimes referred to as “recovery” testing, is not part of the three required test elements and is not valid for determining eligibility for oxygen coverage.

  • Qualifying at sleep - There must be a minimum of 2 hours test time recorded for sleep oximetry.

3) Documentation that alternative measures have been tried or considered and deemed clinically ineffective.

  • While there is no substitute for oxygen therapy, each patient must receive optimum therapy before long-term home oxygen therapy is ordered. Medical documentation must indicate that other forms of treatment (e.g., medical and physical therapy directed at secretions, bronchospasm and infection) have been tried, have not been sufficiently successful, and oxygen therapy is still required.

NOTE:

Coverage of home oxygen therapy requires that the patient be tested in the “chronic stable state.” Chronic stable state is a requirement of the National Coverage Determination and is one of the key criteria when determining coverage of home oxygen therapy. The NCD defines chronic stable state as “…not during a period of an acute illness or an exacerbation of their underlying disease.” Based on this NCD definition, all co-existing diseases or conditions that can cause hypoxia must be treated and the patient must be in a chronic stable state before oxygen therapy is considered eligible for payment. In addition, the patient must have a severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. In the case of OSA, it is required that the OSA be appropriately and sufficiently treated such that the patient is in the chronic stable state before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy.

Overnight oximetry does not include oximetry obtained during polysomnography or other sleep testing for sleep apnea. Example of a patient with OSA where oxygen would be covered: Patient has a diagnosis of OSA as well as a chronic, severe lung disease. During a titration lasting more than 2 hours, the patient is titrated to an optimal pressure and the OSA is resolved, yet continues to desat below 88% for more than five minutes total. In this case, the patient would be in a chronic stable state (obstructive apneas treated) but the patient has continued desaturation. Oxygen therapy would be considered for coverage due to meeting: 1) chronic stable state 2) qualifying desat value 3) severe lung disease. Oxygen therapy is never covered for a diagnosis of OSA but rather co-existing chronic pulmonary conditions.

Overnight Testing Qualifications:

    1. An arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a patient who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or
    2. A decrease in arterial PO 2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent from baseline saturation, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia.

Blood Gas Study Qualifications – Group II:

An arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria), and

Any of the following:

  • Dependent edema suggesting congestive heart failure, or
  • Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
  • Erythrocythemia with a hematocrit greater than 56 percent.

Initial coverage for beneficiaries meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. Group III includes beneficiaries with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these beneficiaries there is a rebuttable presumption of non-coverage.