CurrentAetnaPolicy 0002

Oxygen (Home Oxygen Therapy)

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This policy governs medical necessity, covered delivery systems, reassessment, and coding for home oxygen therapy for Aetna members. It applies to clinicians prescribing and DME suppliers providing domiciliary oxygen equipment.

Policy Summary

PayerAetna

PolicyOxygen (Home Oxygen Therapy)

Policy CodePolicy 0002

Change TypeNo material clinical or coverage changes

Effective DateOct 6, 1995

Last ReviewJun 30, 2023

Next Review DateJan 11, 2024

Key ActionObtain prior authorization documenting the qualifying diagnosis and qualifying blood gas study with required timing and stability conditions before supplying home oxygen DME.

SourceLink

5,136subjects in HFNC systematic review update

PaO2 ≤55 mm Hgprimary hypoxemia threshold

12 mo / 3 moreassessment interval

7,677acute stroke RCT participants

≥6 hrs/wkmin ambulatory use to qualify

Coverage Criteria

Initial therapy

Home oxygen therapy is medically necessary when ALL of the following are met:

Primary requirements: The treating physician determines the member has severe lung disease or hypoxia-related symptoms expected to improve with oxygen therapy; AND the member's blood gas study meets the qualifying criteria; AND the qualifying blood gas study was performed by a physician or qualified provider/supplier; AND the qualifying blood gas was obtained under the specified timing conditions (inpatient: closest to, but no earlier than, 2 days prior to discharge; outpatient chronic: while the member is in a chronic stable state, not during an acute illness or exacerbation); AND alternative treatment measures have been tried or considered and deemed clinically ineffective.

Blood gas study = oximetry or arterial blood gas.

Delivery system coverage

When members meet clinical criteria, the following delivery systems are covered based on mobility and usage:

Stationary concentrators, liquid reservoirs, or large cylinders are covered for members who do not regularly go beyond the limits of a stationary system with 50-ft tubing or who use oxygen only during sleep.

Portable (stroller): Systems ≥10 lbs designed to be transported but not easily carried are covered for members who occasionally go beyond 50-ft tubing for less than 2 hours per day on most days (minimum 2 hours/week).

Preset portable oxygen units are considered not medically necessary.

Ambulatory: Systems <10 lbs designed to be carried by the member (lasting ~4 hours at 2 L/min) are covered for members who regularly go beyond 50-ft tubing for ≥2 hours/day for most days (minimum 6 hours/week).

Prescription based on activity status.

Portable oxygen concentrators and combination stationary/portable systems are considered medically necessary as an alternative to ambulatory systems when the member meets ambulatory criteria and is regularly (at least monthly) away from home for durations that exceed ambulatory system capacity.

HFNC — post-extubation and post-operative use

Covered when evidence-supported criteria are met:

HFNC post-extubation coverage: HFNC may be considered when ALL of the following are met: (1) patient is an adult post-extubation; (2) there is a clinical indication such as risk of post-extubation respiratory failure or the need to prevent re‑intubation; AND (3) conventional oxygen therapy (COT) or noninvasive ventilation is inadequate or not tolerated OR the patient's clinical risk profile favors HFNC (evidence shows reduced post‑extubation respiratory failure and, in some subgroups, reduced re‑intubation).as per RCT/meta-analysis findings

Evidence stronger in certain subgroups (critically ill and post‑operative surgical patients) but heterogeneous across studies.

HFNC — immunocompromised/ICU patients

Considered when ALL of the following are met:

HFNC in immunocompromised acute respiratory failure: HFNC may be used for immunocompromised adults with acute respiratory failure when ALL are met: (1) patient is immunocompromised with acute respiratory failure; (2) clinical judgment supports HFNC as therapy in lieu of or after failure/intolerance of conventional low‑flow oxygen or NIV; AND (3) provider recognizes that meta-analyses report reduced short‑term mortality and intubation rates but evidence certainty is limited by bias and heterogeneity.study-level inclusion criteria applied

Certainty of evidence downgraded; further RCTs needed.

Nocturnal or supplemental O2 in OSA

Covered with criteria:

Supplemental oxygen for OSA nonadherent to CPAP: Supplemental oxygen may be considered when ALL are met: (1) documented obstructive sleep apnea with supporting objective sleep data including AHI and oxygenation measures; (2) documented intolerance or nonadherence to CPAP; AND (3) monitoring and documentation of the effects of supplemental O2 on oxygen saturation and apnea‑hypopnea duration, since O2 improves SpO2 but may prolong apnea/hypopnea episodes.objective sleep study data required

Ensure documentation of AHI and oxygenation response.

Routine supplemental oxygen in acute myocardial infarction (non-hypoxemic)

Not covered / not recommended when ALL of the following apply:

Oxygen in non-hypoxemic suspected MI: Routine supplemental oxygen is not supported for patients with suspected acute myocardial infarction who have normal oxygen saturation (e.g., SpO2 ≥90%); trials and meta-analyses show no mortality benefit and possible increased risk of recurrent MI.normal baseline SpO2 (e.g., ≥90%)

Avoid routine oxygen in non-hypoxemic MI per trial evidence.

Prophylactic low-dose oxygen in acute stroke (non-hypoxemic)

Not covered / not recommended when ALL of the following apply:

Routine prophylactic oxygen in non-hypoxemic acute stroke: Routine low‑dose prophylactic oxygen for non‑hypoxemic acute stroke patients is not supported (no reduction in death or disability at 3 months in a large RCT); do not use prophylactic oxygen in non‑hypoxemic stroke without other clinical indications.baseline SpO2 typically >93%

Evidence from a large RCT (Roffe et al.) does not support benefit.

Home nocturnal oxygen therapy in pregnant women with sickle cell disease

Informational / investigational coverage stance:

Prophylactic nocturnal O2 in SCD pregnancy: Preliminary retrospective data suggest that home nocturnal prophylactic oxygen combined with targeted transfusion may decrease transfusion requirements and transfusion‑associated complications in pregnant women with sickle cell disease; evidence is preliminary and further randomized trials are planned.evidence preliminary

Consider investigational or case‑by‑case coverage pending higher‑level evidence.

Medical necessity criteria

Covered when ALL of the following are met

Continuous Home Oxygen: A physician prescription including required elements AND qualifying laboratory values: resting PaO2 ≤55 mm Hg or SaO2 ≤88%; OR resting PaO2 56–59 mm Hg or SaO2 89% at rest, during sleep for ≥5 minutes, or during exercise in the presence of dependent edema (suggesting CHF), erythrocythemia (Hct >56%), or pulmonary hypertension/cor pulmonale; qualification studies must be done on room air unless medically contraindicated.see qualifying laboratory values in Appendix

Recent hospital test results or pulse oximetry are acceptable documentation.

Non-continuous (ambulatory/exertional/sleep) Oxygen: A physician prescription including required elements AND qualifying laboratory values specific to exercise or sleep: during exercise PaO2 ≤55 mm Hg or SaO2 ≤88% at low exertion with documentation that oxygen improves the exercise hypoxemia; during sleep PaO2 ≤55 mm Hg or SaO2 ≤88% for ≥5 minutes, OR a decrease in PaO2 >10 mm Hg or SaO2 >5% for ≥5 minutes associated with symptoms or signs attributable to hypoxemia. Flow rate and hours per day must be specified.see qualifying laboratory values in Appendix

All qualification studies on room air unless contraindicated.

Borderline values: If resting PaO2 >59 mm Hg or SaO2 >89%, oxygen may be considered only with additional documentation justifying the prescription and a summary of conservative therapies that have failed.N/A

Non-Continuous Oxygen Qualification (Exercise and Sleep)

Covered when ALL of the following are met for the specified context:

Exercise qualification: During exercise: PaO2 ≤55 mm Hg OR oxygen saturation ≤88% with low level of exertion; AND documentation that oxygen use improves the demonstrated exercise hypoxemia when breathing room air.see exercise hypoxemia threshold

Flow rate and number of hours per day must be specified.

Sleep qualification absolute: During sleep: PaO2 ≤55 mm Hg OR oxygen saturation ≤88% for at least 5 minutes.see sleep hypoxemia absolute threshold

All qualification studies must be done while on room air unless medically contraindicated.

Sleep qualification relative: During sleep: a decrease in PaO2 >10 mm Hg OR a decrease in arterial oxygen saturation >5% from baseline for at least 5 minutes, associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cognitive impairment, nocturnal restlessness/insomnia, cor pulmonale, 'P' pulmonale on EKG, documented pulmonary hypertension, erythrocytosis).see sleep hypoxemia relative threshold

General testing: All qualification studies must be performed while breathing room air unless medically contraindicated; blood gas values may be documented from doctor's office, hospital, or outpatient laboratory.

Flow rate and hours per day must be specified.

Oxygen therapy is not medically necessary for indications outside the diagnoses listed in this policy. Examples include angina pectoris without hypoxemia, dyspnea without cor pulmonale or evidence of hypoxemia, severe peripheral vascular disease causing only localized desaturation without systemic hypoxemia, and terminal illnesses that do not affect the respiratory system. Requests for ongoing oxygen for these non-listed indications are subject to medical review and may be denied unless special circumstances or documented qualifying lab values exist.

Routine use of supplemental oxygen is not supported for patients with non-hypoxemic acute myocardial infarction (for example, baseline SpO2 ≥ 90%) based on randomized trials and registry data showing no mortality benefit and possible increased recurrent MI. Similarly, routine prophylactic low‑dose oxygen for non‑hypoxemic acute stroke patients did not reduce death or disability at 90 days in a large randomized trial and therefore is not recommended unless hypoxemia or other specific clinical indications are present.

Home oxygen is not supported as a treatment for pediatric seizures or epilepsy. There is a lack of published clinical studies demonstrating benefit, and clinical resources (UpToDate) do not list oxygen as a therapeutic option for seizure management in children.

No additional explicit exclusions are listed in this excerpt of the policy section beyond those described elsewhere in the document and appendix; qualifying laboratory value rules and testing requirements govern coverage decisions for continuous and non‑continuous oxygen.

Specific items and configurations considered not medically necessary include preset portable oxygen units, emergency or standby oxygen systems, duplicate oxygen systems (for example, provision of both a stationary and portable concentrator or both transfilling and portable systems), and a second spare tank except when the member is continuously oxygen‑dependent. Ambulatory oxygen systems and portable oxygen concentrators are not considered medically necessary when qualification is based solely on sleep blood gas studies.

Routine supplemental oxygen for patients with suspected acute myocardial infarction who are not hypoxemic is not supported by evidence and may increase harm; such use may be denied. Likewise, routine prophylactic low‑dose oxygen in non‑hypoxemic acute stroke patients did not demonstrate benefit in large randomized trials and is excluded unless the patient is hypoxemic or has another clinical indication for oxygen.

For patients with COPD and moderate hypoxemia, pooled trial data suggest that home oxygen probably makes little or no difference to 3‑year mortality. The evidence does not support widespread use of home oxygen in this population without clear qualifying laboratory values.

Within this policy excerpt there are no additional explicit statements of items or indications deemed not medically necessary beyond those already cited; coverage decisions hinge on the qualifying laboratory values and the testing requirements described in the appendix.

Coding

HCPCS codes covered if selection criteria are met / related HCPCSHCPCSCovered

E0424	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0425	Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0430	Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing.
E0431	Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing.
E0433	Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers,regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and content gauge.
E0434	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing.
E0435	Portable liquid oxygen system purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor.
E0439	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0440	Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0441	Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), 1 month's supply = 1 unit.

1–10 of 26

1/3

Other HCPCS codes related to the CPBHCPCSCovered

A4615	Cannula, nasal.
A4616	Tubing (oxygen), per foot.
A4617	Mouthpiece.
A4618	Breathing circuits.
A4619	Face tent.
A4620	Variable concentration mask.
A7046	Water chamber for humidifier, used with positive airway pressure device, replacement, each.

ICD-10 codes covered if selection criteria are met (not all-inclusive)ICD-10Covered

J12.0 - J18.1, J18.8 - J18.9	Pneumonia
J40 - J42, J44.0 - J44.9	Bronchitis and other COPD
J45.20 - J45.998	Asthma
J47.0 - J47.9	Bronchiectasis
J84.10	Pulmonary fibrosis, unspecified
E84.0 - E84.9	Cystic fibrosis
I27.0 - I27.9	Other pulmonary heart diseases
I50.20 - I50.9	Congestive heart failure
Z99.81	Dependence on supplemental oxygen

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)ICD-10Not Covered

G43.001 - G43.919	Migraine
G47.33	Obstructive sleep apnea
I20.0 - I20.9	Angina pectoris
R06.00 - R06.09	Dyspnea without cor pulmonale or evidence of hypoxemia

inv-23: Reassessment intervals — timing and process

Reassessment interval — severe hypoxemia12 months for arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88%

Reassessment interval — borderline hypoxemia with comorbidity3 months for arterial PO2 56–59 mm Hg or arterial oxygen saturation of 89% when dependent edema, 'P' pulmonale, or erythrocythemia are present

Performer and independenceReassessments must be performed by an independent respiratory provider and by an Aetna-participating oxygen‑qualifying company separate from the oxygen supplier

Notification requirementMember's primary care and/or treating physician must be notified for authorization of testing and any treatment changes including discontinuation

inv-24: Oxygen saturation thresholds reported in trials — examples

Stroke trial example — baseline saturationMean baseline SpO2 reported as 96.6% in the large acute stroke RCT

Stroke trial — oxygen dosing ruleOxygen given at 3 L/min if baseline SpO2 ≤ 93% and at 2 L/min if SpO2 > 93%

MI registry example — inclusion saturationIn the Swedish MI registry RCT, patients had oxygen saturation ≥ 90% at enrollment (non-hypoxemic population)

Trial duration/context noteTrials cited used specified flow rates and durations (eg, 6 L/min for 6–12 hours in the MI registry) tied to the trial protocol

inv-25: Qualifying laboratory values — continuous and non-continuous

Continuous oxygen — primary thresholdsResting (awake) PaO2 ≤ 55 mm Hg OR arterial oxygen saturation ≤ 88%

Continuous oxygen — borderline with comorbidityResting PaO2 56–59 mm Hg OR arterial oxygen saturation 89% at rest, during sleep ≥5 minutes, or during exercise in presence of dependent edema, erythrocythemia (Hct >56%), or pulmonary hypertension/cor pulmonale

Non-continuous oxygen — exerciseDuring exercise: PaO2 ≤ 55 mm Hg OR oxygen saturation ≤ 88% with low level of exertion; oxygen is medically necessary if it improves documented exercise hypoxemia

Non-continuous oxygen — sleepDuring sleep: PaO2 ≤ 55 mm Hg OR SpO2 ≤ 88% for ≥5 minutes, OR a decrease in PaO2 >10 mm Hg or SpO2 >5% from baseline for ≥5 minutes associated with symptoms or signs attributable to hypoxemia

inv-26: Exercise hypoxemia threshold

Exercise hypoxemia thresholdPaO2 ≤ 55 mm Hg OR oxygen saturation ≤ 88% during low level of exertion; provision is medically necessary if oxygen use improves the observed exercise hypoxemia when breathing room air

Documentation requirementOxygen flow rate and number of hours per day during exercise must be specified and improvement must be demonstrated on room air

Context of measurementExercise testing must be conducted while the member is breathing room air unless medically contraindicated

inv-27: Sleep hypoxemia absolute threshold

Absolute sleep thresholdPaO2 ≤ 55 mm Hg OR arterial oxygen saturation ≤ 88% for at least 5 minutes during sleep

Duration requirementDesaturation must persist for a minimum of 5 minutes to meet the absolute sleep criterion

Measurement conditionSleep qualification measurements must be performed while breathing room air unless medically contraindicated

inv-28: Sleep hypoxemia relative threshold

Relative sleep thresholdA decrease in PaO2 > 10 mm Hg OR a decrease in arterial oxygen saturation > 5% from baseline for at least 5 minutes during sleep associated with symptoms or signs attributable to hypoxemia

Examples of associated signs/symptomsSymptoms: cognitive impairment, nocturnal restlessness, insomnia; Signs: cor pulmonale, 'P' pulmonale on EKG, documented pulmonary hypertension, erythrocytosis

Minimum durationRelative drop must persist for at least 5 minutes to qualify

inv-29: Testing environment requirement

Room air requirementAll qualification studies must be done while the member is breathing room air unless medically contraindicated

Acceptable documentation sourcesBlood gas/oximetry values can be documented from doctor's office, hospital, or outpatient laboratory

Exception handlingIf medically contraindicated to test on room air, that circumstance should be documented

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Required Documentation

Prior authorization is required. Requests must document a qualifying diagnosis and qualifying oxygenation measurements (PaO2 or SpO2) with the test performed by a physician or qualified provider. The request must state the oxygen flow rate and the number of hours per day the device is to be used, and include a physician prescription with frequency, duration of use, duration of need, and type of system.

Prior authorization must include the qualifying blood gas study (oximetry or arterial blood gas) obtained under the timing/stability rules: if inpatient, the test closest to but no earlier than 2 days before discharge; if outpatient for chronic conditions, during a chronic stable state (not during acute illness or exacerbation).
Specify flow rate and hours per day (continuous vs non-continuous) on the authorization request.
Reassessment testing (pulse oximetry or ABG) is required at 12 months for patients qualifying with PaO2 ≤55 mm Hg or SpO2 ≤88%, or at 3 months for those qualifying with PaO2 56–59 mm Hg or SpO2 89% with dependent edema, P pulmonale, or erythrocythemia.
Reassessments must be performed by an independent oxygen-qualifying company not connected to the oxygen supplier; treating clinician must be notified of testing and any treatment changes.

Documentation Required

Lab-Value Prerequisites and Borderline Values

Document qualifying laboratory values and the context in which they were obtained. When values are borderline, provide additional justification and a summary of conservative therapies tried and their outcomes.

Continuous oxygen qualifying thresholds: resting PaO2 ≤55 mm Hg or arterial oxygen saturation ≤88%; or PaO2 56–59 mm Hg or saturation 89% plus dependent edema, erythrocythemia (hematocrit >56%), or pulmonary hypertension/cor pulmonale.
Non-continuous (specify flow rate and hours/day): exercise: PaO2 ≤55 mm Hg or SpO2 ≤88% with low exertion and documented improvement with oxygen; sleep: PaO2 ≤55 mm Hg or SpO2 ≤88% for ≥5 minutes, or a drop in PaO2 >10 mm Hg or SpO2 >5% for ≥5 minutes during sleep with related symptoms/signs.
If resting PaO2 >59 mm Hg or SpO2 >89%, include documentation justifying oxygen prescription and a summary of conservative therapies tried and failed.

Step Therapy

OSA and Step Approach to HFNC

For patients with obstructive sleep apnea (OSA) who are non-adherent or intolerant to CPAP, include sleep study metrics and clinical response to prior therapies. HFNC or supplemental oxygen may be considered only after documenting failure or intolerance of first-line therapies.

Include apnea-hypopnea index (AHI) from sleep testing and nocturnal oxygenation measures (SpO2 nadir, time below thresholds) on the authorization.
Document prior use and adherence to CPAP (or other first-line therapy), reasons for intolerance or failure, and any physiologic response to supplemental oxygen.
High-flow nasal cannula (HFNC) should generally be reserved as a step after first-line therapies (e.g., CPAP or conventional oxygen therapy) have failed or were not tolerated, particularly for post-extubation or acute respiratory failure indications supported by RCT/meta-analysis evidence.

Documentation Required

Required Prescription Elements

The physician prescription (required documentation) must clearly state the intended use parameters and supporting test results.

Prescription must include: estimated frequency, duration of use (hours/day), duration of need (expected timeframe), type of oxygen delivery system, and prescribed oxygen flow rate.
Attach physician's statement of recent hospital test results or clinic/outpatient lab values (ABG or pulse oximetry) obtained on room air unless contraindicated.
For non-continuous oxygen requests, explicitly state the oxygen flow rate and number of hours per day the device will be used.

Documentation Required

Conservative and Alternative Therapies

Before certifying home oxygen therapy, conservative and alternative treatments must have been tried or considered and documented as clinically ineffective.

Document prior conservative measures (e.g., optimization of medical therapy for underlying lung disease, pulmonary rehabilitation, smoking cessation, nocturnal ventilatory support when indicated) and why these were ineffective or not tolerated.
When oxygenation values are borderline, include a summary of these conservative therapies and rationale for prescribing oxygen despite borderline labs.

Background

Home oxygen therapy is used to treat hypoxemia arising from severe lung disease and other hypoxia‑related conditions (for example, COPD with severe hypoxemia, cystic fibrosis, diffuse interstitial lung disease, bronchiectasis, pediatric bronchopulmonary dysplasia, pulmonary neoplasm, erythrocytosis, pulmonary hypertension, and cor pulmonale). The policy requires documentation of a qualifying blood gas study (oximetry or arterial blood gas) and a physician prescription with specification of flow rate, estimated frequency/duration of use, type of delivery system, and duration of need. Qualification and reassessment intervals depend on the measured oxygenation values and clinical context.

Definitions

inv-47: blood gas study — definition and role

Definition — blood gas studyRefers to either an oximetry test or an arterial blood gas test

Performer requirementQualifying blood gas study must be performed by a physician or by a qualified provider or supplier of laboratory services

Use in policyBlood gas study findings determine medical necessity for home oxygen (continuous or non-continuous) as specified in qualifying laboratory values

inv-48: HFNC (high-flow nasal cannula) — definition and clinical context

HFNC definitionHigh-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated, humidified high‑flow oxygen via nasal cannula and can improve oxygenation

Clinical effect summaryHFNC may reduce intubation or re‑intubation rates and improve tolerance in certain adult populations (eg, post‑extubation critically ill or select post‑operative patients)

Evidence noteBenefit varies by population and study heterogeneity; HFNC evidence stronger in some subgroups (eg, critically ill) as shown in systematic reviews/meta‑analyses

inv-49: HBOT / NBOT — contextual definition

HBOT / NBOT contextHyperbaric (HBOT) and normobaric (NBOT) oxygen therapies have been studied for acute migraine and cluster headache; HBOT has limited availability and cost concerns

Evidence strengthEvidence for HBOT in migraine is sparse and controversial; NBOT is inexpensive and may be used despite limited evidence

Guideline noteNICE recommends oxygen for cluster headaches but evidence for migraine is limited

inv-50: Blood gas study — glossary entry

Blood gas study (glossary)Oximetry test or arterial blood gas test

Role in qualificationUsed to document PaO2 or arterial oxygen saturation values that determine eligibility for home oxygen therapy

Measurement sourcesValues may be obtained from doctor's office, hospital, or outpatient laboratory

inv-51: Erythrocythemia — definition and relevance

Erythrocythemia definitionHematocrit greater than 56% (policy glossary states >56%; related qualifying value references hematocrit >56%)

Role as comorbidityErythrocythemia is a listed comorbidity that can allow qualification with borderline PaO2 (56–59 mm Hg) or SaO2 89%

Documentation implicationErythrocythemia should be documented when used to justify oxygen for borderline gas values

inv-52: Non-Continuous Oxygen — definition and prescribing requirements

Non-continuous oxygen definitionOxygen therapy prescribed for specific periods (eg, during exercise or sleep) where oxygen flow rate and number of hours per day must be specified

Contexts describedIncludes oxygen for exercise (ambulatory) and nocturnal oxygen with explicit flow‑rate/hours requirements and qualifying lab values

Authorization requirementPrior authorization must specify flow rate and hours per day for non-continuous oxygen

Policy Summary

PayerAetna

PolicyOxygen (Home Oxygen Therapy)

Policy CodePolicy 0002

Change TypeNo material clinical or coverage changes

Effective DateOct 6, 1995

Last ReviewJun 30, 2023

Next Review DateJan 11, 2024

Key ActionObtain prior authorization documenting the qualifying diagnosis and qualifying blood gas study with required timing and stability conditions before supplying home oxygen DME.

SourceLink

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Oxygen (Home Oxygen Therapy)

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Coverage Criteria

Initial therapy

Home oxygen therapy is medically necessary when ALL of the following are met:

Blood gas study = oximetry or arterial blood gas.

Delivery system coverage

When members meet clinical criteria, the following delivery systems are covered based on mobility and usage:

Preset portable oxygen units are considered not medically necessary.

Prescription based on activity status.

HFNC — post-extubation and post-operative use

Covered when evidence-supported criteria are met:

Evidence stronger in certain subgroups (critically ill and post‑operative surgical patients) but heterogeneous across studies.

HFNC — immunocompromised/ICU patients

Considered when ALL of the following are met:

Certainty of evidence downgraded; further RCTs needed.

Nocturnal or supplemental O2 in OSA

Covered with criteria:

Ensure documentation of AHI and oxygenation response.

Routine supplemental oxygen in acute myocardial infarction (non-hypoxemic)

Not covered / not recommended when ALL of the following apply:

Avoid routine oxygen in non-hypoxemic MI per trial evidence.

Prophylactic low-dose oxygen in acute stroke (non-hypoxemic)

Not covered / not recommended when ALL of the following apply:

Evidence from a large RCT (Roffe et al.) does not support benefit.

Home nocturnal oxygen therapy in pregnant women with sickle cell disease

Informational / investigational coverage stance:

Consider investigational or case‑by‑case coverage pending higher‑level evidence.

Medical necessity criteria

Covered when ALL of the following are met

Recent hospital test results or pulse oximetry are acceptable documentation.

All qualification studies on room air unless contraindicated.

Non-Continuous Oxygen Qualification (Exercise and Sleep)

Covered when ALL of the following are met for the specified context:

Flow rate and number of hours per day must be specified.

Sleep qualification absolute: During sleep: PaO2 ≤55 mm Hg OR oxygen saturation ≤88% for at least 5 minutes.see sleep hypoxemia absolute threshold

All qualification studies must be done while on room air unless medically contraindicated.

Flow rate and hours per day must be specified.

Coding

HCPCS codes covered if selection criteria are met / related HCPCSHCPCSCovered

E0424	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0425	Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0430	Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing.
E0431	Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing.
E0433	Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers,regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and content gauge.
E0434	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing.
E0435	Portable liquid oxygen system purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor.
E0439	Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0440	Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0441	Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), 1 month's supply = 1 unit.

1–10 of 26

1/3

Other HCPCS codes related to the CPBHCPCSCovered

A4615	Cannula, nasal.
A4616	Tubing (oxygen), per foot.
A4617	Mouthpiece.
A4618	Breathing circuits.
A4619	Face tent.
A4620	Variable concentration mask.
A7046	Water chamber for humidifier, used with positive airway pressure device, replacement, each.

ICD-10 codes covered if selection criteria are met (not all-inclusive)ICD-10Covered

J12.0 - J18.1, J18.8 - J18.9	Pneumonia
J40 - J42, J44.0 - J44.9	Bronchitis and other COPD
J45.20 - J45.998	Asthma
J47.0 - J47.9	Bronchiectasis
J84.10	Pulmonary fibrosis, unspecified
E84.0 - E84.9	Cystic fibrosis
I27.0 - I27.9	Other pulmonary heart diseases
I50.20 - I50.9	Congestive heart failure
Z99.81	Dependence on supplemental oxygen

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)ICD-10Not Covered

G43.001 - G43.919	Migraine
G47.33	Obstructive sleep apnea
I20.0 - I20.9	Angina pectoris
R06.00 - R06.09	Dyspnea without cor pulmonale or evidence of hypoxemia