CurrentCentenePolicy CP MP.190

Outpatient Oxygen Use

Defines medical necessity criteria, initial authorization and reauthorization requirements, pediatric criteria, exclusions, cluster headache criteria for outpatient/home oxygen concentrators and oxygen delivery systems, and related coding implications for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyOutpatient Oxygen Use

Policy CodePolicy CP MP.190

Change TypeCriteria clarification and operational updates

Effective Date

Next Review Date

Key ActionProviders must obtain prior authorization demonstrating all initial or reauthorization criteria are met, including documentation of qualifying blood gas/oximetry and physician evaluation within specified timeframes.

POLICY UPDATE CHANGES

Updated all instances of 'blood gas study' to include 'or oximetry measurement' and arterial oxygen saturation to include '(or pulse oximetry)'; changed age requirements from >=21 to >=18.

Removed criteria I.C requiring qualifying blood gas/oximetry to be performed by physician or qualified laboratory provider.

Added that DME companies are prohibited from obtaining reauthorization oxygen tests; IDTFs or physician/designee must perform them; home oxygen companies may coordinate with IDTF.

Added pediatric-specific SpO2 thresholds and portable oxygen criteria for children.

>=18Adult age threshold for primary criteria

<18Pediatric-specific criteria apply

PaO2<=55 / SpO2<=88%

Primary hypoxemia threshold

E0424-E0447, E1390-E1392...HCPCS codes referenced

Coverage Summary

coverage_stance: covered_with_criteria; subject: Outpatient oxygen therapy (concentrators and oxygen systems); policy_number: CP MP.190; status: CURRENT; effective/last_review: last_review 2024-11-24. Scope: defines medical necessity for initial approval and reauthorization of outpatient oxygen concentrators and oxygen systems for beneficiaries aged >=18 years with separate pediatric criteria for those <18 years, plus exclusions and cluster headache criteria. Primary hypoxemia thresholds: resting PaO2 <= 55 mm Hg or resting SpO2 <= 88%. Borderline/Group II thresholds: PaO2 56–59 mm Hg or SpO2 <= 89% when accompanied by qualifying conditions (e.g., cor pulmonale, pulmonary hypertension, erythrocytosis). Pediatric SpO2 thresholds: for <1 year, SpO2 < 90% during 5% of recording time or three independent readings <90%; for >=1 year, SpO2 < 93% during 5% of recording time or three independent readings <93%.

Quick reference thresholds and codes

Primary hypoxemia thresholdPaO2 <= 55 mm Hg OR SpO2 <= 88% (rest, awake, breathing room air)

Borderline thresholdsPaO2 56-59 mm Hg OR SpO2 <= 89% when accompanied by cor pulmonale/pulmonary hypertension, dependent edema suggesting CHF, or erythrocytosis (hematocrit >56%)

Adult age thresholdAdults: age >= 18 years

Pediatric thresholds<1 year: SpO2 <90% during >=5% of recording time OR three independent SpO2 measurements <90% if intermittent; >=1 year: SpO2 <93% during >=5% recording time OR three independent measurements <93% if intermittent

Portable oxygen notePortable systems require patient mobility in home/community and qualifying test performed at rest (awake) or during exercise (sleep-only measurements do not qualify)

HCPCS codes referencedE0424-E0447, E1390-E1392, E1405-E1406, K0738, S8120-S8121

Medical-Necessity Criteria — Initial Approval (Adults ≥18)

Initial approval for members/enrollees >= 18 years

Initial approval of oxygen concentrators and oxygen systems (excluding cluster headaches stationary systems) is medically necessary when ALL of the following are met:

ALL of the following

A: Physician-documented severe disease or hypoxemia-related symptoms that might be expected to improve with oxygen therapy
Group I - resting, sleep, or exercise thresholds
- I.a - Resting: Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation (or pulse oximetry) at or below 88% taken at rest (awake), breathing room airPaO2 <=55 mm Hg or SpO2 <=88%

Medical-Necessity Criteria — Group II (Borderline Hypoxemia)

Group II (rare cases) - borderline hypoxemia

Criteria describing PaO2 56-59 mm Hg or SpO2 89% with accompanying conditions

Group II - borderline hypoxemia

AND at least one of
- a: Dependent edema suggesting congestive heart failure
- b: Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood scan, echocardiogram, or 'P' pulmonale on EKG
- c: Erythrocythemia with hematocrit greater than 56 percent

Medical-Necessity Criteria — Pediatric Initial Approval (<18 years)

Pediatric initial approval (<18 years)

Initial approval for members/enrollees < 18 years is medically necessary when ALL of the following are met:

ALL of the following

A: Physician-documented severe disease or hypoxemia-related symptoms expected to improve with oxygen therapy (permitted diagnoses list, not all-inclusive)
Permitted diagnoses include but are not limited to
- 1: Chronic lung disease of prematurity
- 2: Cystic fibrosis complicated by severe chronic hypoxemias

Medical-Necessity Criteria — Reauthorization (Adults)

Reauthorization for adults (>=18 years)

Reauthorization of oxygen concentrators and other supplemental oxygen delivery systems are medically necessary when ALL of the following are met:

ALL of the following

A: Evaluation by the treating physician within 30 days prior to the date of recertification
Reauthorization testing and documentation
- 1: A new recorded (overnight recommended) oximetry tracking, study report, or blood gas result documents that the member still meets the initial authorization criteria in Section II, and the measurement was obtained within 30 days of the recertification date and by the physician or designee or by an independent diagnostic testing facility (IDTF)Obtained within 30 days and by physician/designee or IDTF
  DME companies prohibited from obtaining reauthorization oxygen tests; home oxygen companies may coordinate with IDTF

Medical-Necessity Criteria — Reauthorization (Pediatrics)

Reauthorization for pediatrics (<18 years)

Reauthorization criteria for patients <18 years (including medically fragile and EPSDT) are medically necessary when meeting criteria analogous to adult reauthorization and age-specific testing requirements

ALL of the following

A: Evaluation by treating physician within 90 days prior to the date of recertification (pediatric-specific requirement)
B: Repeat ABG/oximetry demonstrating continued need as per initial pediatric thresholds (younger than 1 year: SpO2 <90% during 5% recording time or 3 independent measures <90%; 1 year or older: SpO2 <93% during 5% recording time or 3 independent measures <93%)Age-specific pediatric thresholds
Portable:

Not Medically Necessary / Exclusions

Not medically necessary / exclusions

Oxygen concentrators are not medically necessary for the following indications:

Exclusions

1: Breathlessness without cor pulmonale or evidence of hypoxemia
2: Angina pectoris in the absence of hypoxemia
3: Severe peripheral vascular disease resulting in clinically evident desaturation in extremities but without systemic hypoxemia
4:

Cluster Headache — Oxygen Systems for Acute Attacks

Stationary gaseous/liquid oxygen systems for cluster headaches (Section VI)

Stationary gaseous oxygen systems and related delivery equipment for cluster headaches are medically necessary when ALL of the following are met:

ALL of the following

Diagnosis of cluster headache as evidenced by all required diagnostic elements
Frequency: At least five severe to very severe unilateral headache attacks lasting 15 to 180 minutes when untreated5+ attacks lasting 15-180 minutes
AND at least one of accompanying ipsilateral symptoms
- a:

Coding

Covered HCPCS for oxygen systems, concentrators, contents, and related equipmentHCPCSCovered

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
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, and refill adaptor tubing
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	Stationary oxygen contents, gaseous, 1 month's supply = 1 unit

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Provider Actions

Prior Authorization

Prior authorization required per medical necessity criteria

Providers must obtain prior authorization demonstrating all initial or reauthorization criteria are met. Timeframe requirements: for initial requests follow the test timing rules (including inpatient test closest to but no earlier than 2 days before discharge or outpatient testing performed when treating practitioner noted signs/symptoms relieved by home oxygen). For reauthorization: adults require a treating physician evaluation within 30 days prior to the recertification date; pediatrics require evaluation within 90 days prior to recertification.

Initial: follow qualifying test timing rules; inpatient test must be closest to but no earlier than 2 days prior to discharge
Reauth (adults): treating physician evaluation within 30 days prior to recertification
Reauth (pediatrics): treating physician evaluation within 90 days prior to recertification

Documentation Required

Background & Evidence

Oxygenation is the passive diffusion of oxygen from alveoli to pulmonary capillaries where it binds hemoglobin or dissolves in plasma; a low arterial oxygen partial pressure is termed hypoxemia and may result from hypoventilation, V/Q mismatch, shunt, diffusion limitation, or low inspired oxygen. Common tests to assess oxygenation and identify hypoxemia include arterial oxygen tension (PaO2), arterial/oximeter oxygen saturation (SaO2/SpO2), the alveolar-arterial (A-a) oxygen gradient, and PaO2/FiO2 ratio. Guidelines supporting LTOT include the AARC clinical practice guidance and the American Thoracic Society (ATS) Home Oxygen Therapy (HOT) guideline (2020), which endorses LTOT for severe resting hypoxemia and provides condition-specific recommendations (for example, ILD). The ATS review notes scarce and inconclusive data for prescribing oxygen to patients who are normoxic at rest but desaturate with exertion, and evidence for exertional desaturation is limited.

Reference	Notes
NCD 240.2	Referenced for Medicare alignment regarding home use of oxygen (national coverage determination).
ATS HOT guideline (2020)	Supports LTOT for severe resting hypoxemia and provides recommendations for ILD and limited evidence for exertional desaturation.

Definitions

Definitions and operational notes

LTOTContinuous long-term oxygen therapy (LTOT)

IDTFIndependent Diagnostic Testing Facility (IDTF); permitted to perform reauthorization oximetry/ABG testing; DME companies are prohibited from obtaining reauthorization oxygen tests

LOMNLetter of Medical Necessity (LOMN) documenting chronic hypoxemia not expected to resolve or expected to worsen for reauthorization

Medicare Determinations

Determination	Effective Date / Number
NCD 240.2 (Home use of oxygen)	Effective 2021-09-27 / Number: 240.2
LCD L33797 (Oxygen and oxygen equipment)	Effective 2015-10-01 / Number: L33797

Revision History

2024-01-24revisedLatest

Revised — Updated all instances of 'blood gas study' to include 'or oximetry measurement' and arterial oxygen saturation to include '(or pulse oximetry)'; changed age requirements from >=21 to >=18; clarified sleep measurement timing (after 5 minutes).

2024-11-24revisedLatest

Revised — Removed criteria requiring qualifying blood gas/oximetry to be performed by a physician or qualified laboratory provider; added E0447 to coding.

2024-11-24

Policy Summary

PayerCentene

PolicyOutpatient Oxygen Use

Policy CodePolicy CP MP.190

Change TypeCriteria clarification and operational updates

Effective Date

Next Review Date

On This Page

I.b - Sleep: Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation (or pulse oximetry) at or below 88% taken after 5 minutes of sleep for a beneficiary who demonstrates arterial PO2 >=56 mm Hg or arterial oxygen saturation (or oximetry) >=89% while awakePaO2 <=55 mm Hg or SpO2 <=88% (sleep) with awake >=56/89%

Measurement must be obtained after 5 minutes of sleep

I.c - Exercise: Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation (or pulse oximetry) at or below 88% taken during exercise for a beneficiary who demonstrates arterial PO2 >=56 mm Hg or arterial oxygen saturation (or oximetry) >=89% while at rest; oxygen provided for exercise only if documented that oxygen improves the exercise-associated hypoxemia when breathing room airPaO2 <=55 mm Hg or SpO2 <=88% (exercise) with rest >=56/89%

Test timing for inpatient stays: If qualifying measurement obtained during inpatient hospital stay, the reported test must be the one obtained closest to but no earlier than two days prior to hospital discharge; if not inpatient, the test must have been performed when treating practitioner noted signs/symptoms relieved by home oxygen

Portable oxygen requirements: If request is for a portable oxygen system, BOTH: member/enrollee is mobile within the home/community; and qualifying blood gas or oximetry was performed while at rest (awake) or during exercise (measurements only during sleep alone do not qualify for portable oxygen)

Test timing: Qualifying blood gas study or oximetry obtained under allowed conditions: if inpatient, test closest to but no earlier than two days prior to discharge; if outpatient, when treating practitioner noted signs/symptoms relieved by oxygen

3: Bronchopulmonary dysplasia (BPD) complicated by chronic hypoxemias

4: Acute pulmonary/respiratory disease with persistent type I (hypoxic) respiratory failure to facilitate earlier discharge when safe

5: Agenesis, hypoplasia, dysplasia of the lung

6: Chronic cardiopulmonary disease (cor pulmonale)

7: P pulmonale (right atrial enlargement) on EKG

8: Pulmonary hypertension without congenital heart disease complicated by chronic hypoxemia

9: Interstitial lung disease complicated by severe chronic hypoxemias

Age-specific laboratory thresholds

<1 year: For children younger than 1 year: SpO2 < 90% during 5% of recording time; OR three independent measurements of SpO2 < 90% if measurements are taken intermittentlySpO2 <90% during 5% recording time or 3 independent measurements <90%
>=1 year: For children 1 year or older: SpO2 < 93% during 5% of recording time; OR three independent measurements of SpO2 < 93% if measurements are taken intermittentlySpO2 <93% during 5% recording time or 3 independent measurements <93%
Portable: If request is for portable oxygen system, member is mobile within home or community

2: A new ABG or oximetry result documents member still meets initial criteria and for Group II (PO2 56-59 or SpO2 89%) a repeat ABG or oximetry must be obtained within 30 days of recertification dateRepeat ABG/oximetry within 30 days for Group II

Portable oxygen: If request is for portable oxygen system, member is mobile within home or community

LOMN: Chronic hypoxemia is not expected to resolve or is expected to worsen, documented in an explanatory letter of medical necessity (LOMN)

If request is for a portable oxygen system, member is mobile within home or community

Shortness of breath or dyspnea in a pediatric patient without evidence of hypoxemia

5: Terminal illnesses that do not affect the ability to breathe

Ipsilateral conjunctival injection and/or lacrimation

b: Ipsilateral nasal congestion and/or rhinorrhea

c: Ipsilateral eyelid edema

d: Ipsilateral miosis and/or ptosis

e: Ipsilateral forehead and facial sweating

f: A sense of restlessness or agitation

Attack frequency: Frequency of headache attacks occur between one every other day and eight per day1 every 2 days to 8/day

Document qualifying test timing and results

Document the timing and results of the qualifying blood gas or oximetry. If the qualifying measurement was obtained during an inpatient stay, report the test obtained closest to but no earlier than two days prior to hospital discharge. For Group II reauthorization (PaO2 56–59 mm Hg or SpO2 89%), a repeat ABG or oximetry must be obtained within 30 days of the recertification date.

Documentation Required

Portable oxygen specific documentation

For portable oxygen requests, document that the member is mobile within the home/community and that the qualifying blood gas or oximetry was obtained while at rest (awake) or during exercise. Measurements obtained only during sleep do not qualify for portable oxygen.

Confirm patient mobility within home or community
Qualifying measurement must be at rest (awake) or during exercise — sleep-only measurements do not qualify

Billing Rule

Use listed HCPCS codes for devices and contents

Bill using the specified HCPCS codes for devices and contents. Indicate purchase versus rental as appropriate and bill oxygen contents in monthly units where applicable.

E0424
E0425
E0430
E0431
E0433
E0434
E0435
E0439
E0440
E0441
E0442
E0443
E0444
E0445
E0447
E1390
E1391
E1392
E1405
E1406
K0738
S8120
S8121

Documentation Required

Independent testing facility (IDTF) use for reauthorization testing

Reauthorization testing may be performed by the treating physician or designee or by an independent diagnostic testing facility (IDTF). DME/home oxygen companies may not perform the reauthorization oxygen test themselves; home oxygen companies may coordinate with an IDTF to obtain required overnight oximetry. For Group II reauth, a repeat ABG or oximetry is required within 30 days of recertification.

Reauth testing may be done by physician/designee or an IDTF
DME providers/home oxygen companies cannot perform the reauth test themselves
Home oxygen companies may coordinate with an IDTF to obtain overnight oximetry
Group II reauth requires repeat ABG/oximetry within 30 days of recertification

Clarified — Operational rule that DME companies are prohibited from obtaining reauthorization oxygen tests; reauthorization testing must be performed by physician/designee or by an independent diagnostic testing facility (IDTF); home oxygen companies may coordinate with an IDTF to obtain overnight oximetry.

2024-01-24addedLatest

Added — Pediatric-specific SpO2 thresholds and portable oxygen criteria for children (age-based saturation thresholds and mobility requirement for portable systems).