ModifiedAmbetter NevadaPolicy CP.MP.190

Outpatient Oxygen Use (Clinical Policy)

Clinical coverage criteria for outpatient/home oxygen therapy, portable systems, and related equipment for pediatric and adult members/enrollees of Ambetter Nevada (Centene-affiliated health plans).

Policy Summary

PayerAmbetter Nevada

PolicyOutpatient Oxygen Use (Clinical Policy)

Policy CodePolicy CP.MP.190

Change TypeMaterial revisions to criteria, age thresholds, coding, and recertification timing

Effective Date

Next Review Date

Key ActionObtain physician evaluation and qualifying ABG or pulse oximetry within required timeframes for initial authorization and recertification (90‑day window for reauthorization).

SourceLink

POLICY UPDATE CHANGES

Updated all criteria instances of 'blood gas study' to include 'or pulse oximetry measurement' and all instances of 'arterial oxygen saturation' to include '(or pulse oximetry)'.

Changed age requirements in adult criteria from ≥21 to ≥18 years and pediatric criteria from <21 to <18 years.

Added CPT/HCPCS code E0447 to the coding table (portable liquid oxygen contents, 1 month's supply).

Edited portable oxygen criteria to include option for 'mobile within community' in addition to 'within the home' and reorganized portable oxygen criteria; added pediatric portable oxygen system criteria.

Updated recertification timing requirement from 30 days to 90 days prior to the date of recertification.

8initial approval criteria items for adults

90physician evaluation window (days)

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Coverage Criteria for Outpatient/Home Oxygen Therapy

Initial therapy — Adults (≥18 years)

Covered when ALL of the following are met:

Adult initial criteria: Physician-documented severe lung disease or hypoxemia-related symptoms that might be expected to improve with oxygen therapy (I.A).

Group I blood gas/oximetry thresholds: Member qualifies for Group I by meeting any of: (a) an arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation (or pulse oximetry) ≤ 88% at rest (awake) on room air; (b) an arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation (or pulse oximetry) ≤ 88% during sleep for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or oxygen saturation (or pulse oximetry) ≥ 89% while awake; (c) a decrease in arterial PO2 > 10 mm Hg or a decrease in arterial oxygen saturation (or pulse oximetry) > 5% from baseline during sleep associated with symptoms/signs attributable to hypoxemia; (d) an arterial PO2 ≤ 55 mm Hg or arterial oxygen saturation (or pulse oximetry) ≤ 88% during exercise for a beneficiary who demonstrates PO2 ≥ 56 mm Hg or arterial oxygen saturation (or pulse oximetry) ≥ 89% at rest and where supplemental oxygen improves exercise hypoxemia (I.B.1 a–d).

Group II blood gas/oximetry thresholds: Member qualifies for Group II by meeting BOTH: (a) an arterial PO2 of 56–59 mm Hg or arterial blood oxygen saturation ≤ 89% at rest/sleep/exercise; AND (b) one of: dependent edema suggesting CHF; pulmonary hypertension or cor pulmonale (documented by pulmonary artery pressure measurement, gated blood pool scan, echocardiogram, or P pulmonale on EKG); or erythrocythemia with hematocrit > 56% (I.B.2 a–b & i–iii).

Timing/setting of qualifying measurement: Qualifying blood gas study or pulse oximetry measurement was obtained either (a) during an inpatient hospital stay (the test obtained closest to, but no earlier than 2 days prior to, discharge) OR (b) outside an inpatient stay when the treating practitioner noted signs/symptoms of illness that can be relieved by home oxygen (I.C 1–2).

Portable oxygen additional conditions: If the request is for a portable oxygen system, BOTH of the following are required: (1) member is mobile within the home or community; AND (2) the qualifying blood gas study or pulse oximetry measurement was performed while at rest (awake) or during exercise. Note: if the only qualifying measurement was performed during sleep, portable oxygen will be denied (I.D.1–2 and note).

Initial therapy — Pediatrics (<18 years)

Covered when ALL of the following are met:

Pediatric clinical diagnoses: Physician-documented severe lung disease or hypoxemia-related symptoms that might be expected to improve with oxygen therapy; examples include chronic lung disease of prematurity; cystic fibrosis complicated by severe chronic hypoxemia; acute pulmonary/respiratory disease with persistent type I hypoxic respiratory failure to facilitate earlier safe discharge; bronchopulmonary dysplasia with chronic hypoxemia; agenesis/hypoplasia/dysplasia of the lung; chronic cardiopulmonary disease (cor pulmonale); P pulmonale on EKG; causes of chronic hypoxemia (alveolar hypoventilation, V/Q mismatch, shunting, diffusion impairment); pulmonary hypertension without CHD complicated by chronic hypoxemia; interstitial lung disease with severe chronic hypoxemia (II.A items 1–10).

Pediatric oximetry/lab thresholds: Children < 1 year: SpO2 ≤ 90% during ≥5% of the recording time OR three independent measurements of SpO2 ≤ 90% if intermittent. Children ≥ 1 year: SpO2 ≤ 93% during ≥5% of the recording time OR three independent measurements of SpO2 ≤ 93% if intermittent (II.B.1–2).

Portable oxygen additional condition (peds): If the request is for a portable oxygen system, the member/enrollee must be mobile within the home or community (II.C).

Reauthorization — Adults (≥18 years)

Covered when ONE of the following physician-documented conditions is met and evaluation requirements are fulfilled:

Reauthorization pathways: (1) Chronic hypoxemia is not expected to improve or is expected to worsen, documented in an explanatory letter of medical necessity; (2) treatment is for nocturnal hypoxemia in a member who qualifies for Group I and two prior oxygen requests have already been authorized; (3) a new ABG or pulse oximetry documents continued qualification per initial criteria — with timing requirements: for Group I, measurement obtained within 90 days of recertification and by physician/designee or IDTF (DME-obtained O2 levels do not qualify); for Group II (rare cases initially certified for 3 months for PO2 56–59 or O2 sat 89%), a repeat ABG/oximetry must be obtained within 30 days of recertification (III.A.1–3 and subitems).

Portable oxygen reauth conditions: If requesting portable oxygen, BOTH of the following must be met: (1) member is mobile within the home or community; AND (2) the qualifying blood gas study or pulse oximetry measurement was performed while at rest (awake) or during exercise. Note: measurements obtained only during sleep will result in denial (III.B and note).

Reauthorization — Pediatrics (<18 years)

Covered when ALL of the following are met:

Pediatric reauth documentation: Evaluation by the treating physician within 90 days prior to the date of recertification AND either (a) chronic hypoxemia is not expected to resolve or is expected to worsen, documented in an explanatory letter of medical necessity; OR (b) a new recorded pulse oximetry (overnight recommended), sleep study report, or blood gas result documents continued qualification per initial pediatric criteria, obtained within 30 days of recertification and by the physician or designee or by an independent diagnostic testing facility (O2 levels obtained by DME providers do not qualify) (IV.A–B).

Pediatric portable oxygen reauth: If request is for a portable oxygen system, the member/enrollee must be mobile within the home or community (IV.C).

Not medically necessary / Exclusions

Explicit non-indications: Oxygen concentrators are not medically necessary for: (A) angina pectoris in the absence of hypoxemia; (B) breathlessness without cor pulmonale or evidence of hypoxemia; (C) severe peripheral vascular disease with local desaturation in the absence of systemic hypoxemia; (D) shortness of breath or dyspnea in a pediatric patient without evidence of hypoxemia; (E) terminal illnesses that do not affect the ability to breathe (V.A–E).

Cluster headache indication (stationary gaseous oxygen)

Covered when ALL diagnostic criteria for cluster headache are met:

Cluster headache diagnostic criteria: Diagnosis of cluster headache evidenced by all of the following: (1) at least five severe to very severe unilateral headache attacks lasting 15–180 minutes when untreated; (2) headaches accompanied by at least one ipsilateral autonomic feature (a. conjunctival injection and/or lacrimation; b. nasal congestion and/or rhinorrhea; c. eyelid edema; d. forehead/facial sweating; e. miosis and/or ptosis; f. sense of restlessness or agitation); and (3) attack frequency between one every other day and eight per day (VI.A.1–3 and VI.A.3 a–f).

Key updated coverage criteria highlights

Policy applies to severe lung disease and hypoxemia-related symptoms; criteria updated to specify measurement methods and age thresholds.

Measurement methods: Qualifying oxygenation measurements may be obtained via arterial blood gas study or pulse oximetry (policy language updated to accept either).blood gas study or pulse oximetry

Referenced throughout criteria; change modifies accepted test types.

Age thresholds: Adult criteria apply to members aged >= 18 years; pediatric criteria apply to members < 18 years.>=18 / <18

Age thresholds were changed from prior >=21 / <21.

Mobility for portable oxygen: Portable oxygen eligibility includes individuals who are mobile within the community as well as within the home.mobile within community or within home

The policy specifies that stationary and portable oxygen systems are covered only when the member meets the documented medical necessity criteria. For reauthorization, coverage requires either documentation that chronic hypoxemia is not expected to resolve or a new recorded pulse oximetry, sleep study report, or blood gas result that demonstrates continued qualification. The new measurement must be obtained within 30 days of the recertification date and must be performed by the treating physician, the physician’s designee, or an independent diagnostic testing facility (O2 levels obtained by DME providers do not qualify). If a portable oxygen system is requested, the member must be mobile within the home or community at the time of request.

Editorial and administrative updates to the policy clarified accepted measurement methods and timing without changing clinical thresholds. The policy language was revised to accept either an arterial blood gas study or a pulse oximetry measurement throughout the criteria and the adult age threshold was lowered to ≥18 years while pediatric criteria apply to members <18 years. Recertification timing was changed from 30 days to 90 days prior to the date of recertification for required physician evaluation documentation; these are administrative timing and scope changes and do not alter the defined physiologic thresholds for medical necessity.

The policy lists explicit non‑indications for oxygen concentrators. Oxygen is not medically necessary for angina pectoris in the absence of hypoxemia; breathlessness without cor pulmonale or objective hypoxemia; severe peripheral vascular disease with localized desaturation but without systemic hypoxemia; shortness of breath or dyspnea in pediatric patients without evidence of hypoxemia; and terminal illnesses that do not affect the ability to breathe. The policy edits also clarified examples and added language to distinguish local desaturation from systemic hypoxemia.

A cost‑efficiency rule applies: when a medically necessary, lesser‑cost item exists and will meet the member’s medical needs, a higher‑cost item may be denied. This requirement is reflected in the policy’s step‑therapy and provider‑action statements and affects equipment selection and prior authorization decisions.

HCPCS/CPT Codes and Clinical Thresholds

Covered HCPCS for oxygen systems and supplies (group 1)HCPCSCovered

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 contents 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, & tubing.
E0440	Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing.
E0441	Stationary oxygen contents, gaseous, 1 month's supply = 1 unit.

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Covered HCPCS for concentrators and enrichment systems (group 2)HCPCSCovered

E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate.
E1391	Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each.
E1392	Portable oxygen concentrator, rental.
E1405	Oxygen and water vapor enriching system with heated delivery.
E1406	Oxygen and water vapor enriching system without heated delivery.

Additional HCPCS and supply codesHCPCSCovered

K0738	Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing.
S8120	Oxygen contents, gaseous, 1 unit equals 1 cubic foot.
S8121	Oxygen contents, liquid, 1 unit equals 1 pound.

Covered HCPCS/CPT codes for oxygen equipment and contentsHCPCSCovered

E0447	Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (LPM).
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate.
E1391	Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each.
E1392	Portable oxygen concentrator, rental.
E1405	Oxygen and water vapor enriching system with heated delivery.
E1406	Oxygen and water vapor enriching system without heated delivery.
K0738	Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing.
S8120	Oxygen contents, gaseous, 1 unit equals 1 cubic foot.
S8121	Oxygen contents, liquid, 1 unit equals 1 pound.

inv-16: Adult resting oxygen thresholds — PaO2 ≤ 55 mmHg or SpO2 ≤ 88%; Group II criteria with additional clinical findings.

Primary resting thresholdPaO2 ≤ 55 mmHg OR SpO2 ≤ 88% (measured at rest, awake, on room air)

Group II thresholdPaO2 56–59 mmHg OR SpO2 ≤ 89%

Group II additional findings requiredMust have one of: dependent edema suggesting congestive heart failure, pulmonary hypertension/cor pulmonale, or erythrocythemia (hematocrit >55–56%)

Exercise or sleep criteria notePaO2 ≤ 55 mmHg or SpO2 ≤ 88% during exercise or sleep may qualify when daytime rest values are higher and supplemental oxygen improves hypoxemia

inv-17: Pediatric oximetry thresholds — age-specific SpO2 thresholds and recording requirements.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient/home oxygen systems — both for initiation and for reauthorization. Document the treating physician’s evaluation and submit required recertification materials in a timely manner.

Prior authorization required for initiation and reauthorization of oxygen concentrators and oxygen systems.
Letter of medical necessity and recertification documentation should be submitted in advance (see recertification timing rules).

Denial Risk

Portable Oxygen — Denial Condition

If the only qualifying arterial blood gas or pulse oximetry measurement was performed during sleep, requests for portable oxygen will be denied as not reasonable and necessary. Portable systems require documented member mobility within the home or community and a qualifying measurement obtained while awake (rest) or during exercise.

Key Definitions

Oxygen therapy provides supplemental oxygen when ambient oxygen is insufficient to maintain adequate arterial oxygenation. The policy aligns with common LTOT practice by referencing objective measurements (arterial blood gas or pulse oximetry) to document hypoxemia and by applying defined physiologic thresholds for long‑term therapy. The document also clarifies operational items relevant to outpatient use—such as who may perform qualifying measurements, timing of documentation for initial and repeat authorization, and mobility requirements for portable systems—to ensure appropriate use of home oxygen resources.

inv-31: Definition — Oxygen therapy (administration at concentrations > ambient air).

DefinitionAdministration of oxygen at concentrations greater than ambient air (20.9%) to treat or prevent symptoms and manifestations of hypoxemia

PurposeUsed to treat hypoxemia from causes such as hypoventilation, V/Q mismatch, shunt, diffusion limitation, or low inspired oxygen

Measurement relevanceCommon measurements to assess need include PaO2 and SaO2/SpO2

inv-32: Definition — LTOT (long-term oxygen therapy) for chronic lung disease meeting lab thresholds.

Policy Summary

PayerAmbetter Nevada

PolicyOutpatient Oxygen Use (Clinical Policy)

Policy CodePolicy CP.MP.190

Change TypeMaterial revisions to criteria, age thresholds, coding, and recertification timing

Effective Date

Next Review Date

Key ActionObtain physician evaluation and qualifying ABG or pulse oximetry within required timeframes for initial authorization and recertification (90‑day window for reauthorization).

SourceLink

On This Page

inv-19: Recertification submission window — 90 days prior to date of recertification.

Recertification submission windowDocumentation and evaluation must be submitted within 90 days prior to the date of recertification

Physician evaluation timingEvaluation by the treating physician is required within the 90-day recertification window

Measurement timeliness for Group I reauthFor Group I, qualifying measurement must be obtained within 90 days of recertification and by physician/designee or IDTF (DME-obtained O2 levels do not qualify)

Denial Risk

Cost-efficiency / Lower-cost Alternative Rule

A higher-cost item may be denied when a medically necessary, lower-cost alternative exists that will meet the member’s needs. Ensure documentation supports why a higher-cost device is required if choosing it over a suitable lower-cost option.

If a medically necessary, lesser-cost item exists and will suit the member’s needs, a higher-cost item will be denied.
Document clinical rationale when higher-cost equipment is sought despite available lower-cost alternatives.

Documentation Required

Reauthorization Evaluation and Test Timing

For reauthorization, the treating physician must evaluate the member within 90 days prior to the recertification date. When indicated, a new arterial blood gas (ABG) or pulse oximetry result must be obtained per the timing rules (Group I: within 90 days by physician/designee or IDTF; Group II: within 30 days). O2 levels obtained by DME providers do not qualify.

Evaluation by treating physician required within 90 days prior to recertification.
New ABG/oximetry must meet timing and provider-source requirements: Group I within 90 days by physician/designee or IDTF; Group II within 30 days.
O2 measurements obtained by DME providers do not qualify for recertification.

inv-33: Definition — blood gas study or pulse oximetry measurement — qualifying measurement methods; policy updated to accept either.

Accepted measurement methodsQualifying oxygenation measurements may be obtained via arterial blood gas study OR pulse oximetry (policy updated to accept either)

Documentation requirementQualifying ABG or pulse oximetry results must be documented by the physician/designee or an IDTF for reauthorization (DME-obtained results do not qualify)

Policy change noteAll criteria instances of 'blood gas study' and 'arterial oxygen saturation' were updated to include pulse oximetry