CurrentHighmark DelawarePolicy N/A

Home oxygen therapy (Certificate of Medical Necessity)

Forms and clinical requirements for requesting home oxygen therapy (stationary or portable) from the payer; governs documentation and testing needed to establish medical necessity for members receiving oxygen in the home.

Policy Summary

PayerHighmark Delaware

PolicyHome oxygen therapy (Certificate of Medical Necessity)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument a typed office note and a room-air ABG or oxygen saturation within 30 days, include equipment requested and highest ordered flow; if >4 LPM provide test results on 4 LPM.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysABG/pulse oximetry age limit

>=56-59 / >=89%Borderline PO2/sat threshold

4 LPMHigh-flow threshold

room airMeasurement condition

Coverage Criteria for Home Oxygen Therapy

Medical necessity criteria (form-driven)

Covered when documentation demonstrates the following (as applicable):

Core documentation and testing: Typed office note with pertinent information; ABG or oxygen saturation test performed on room air within 30 days of request; physician signature; documentation that the patient was in a chronic stable state when tested.

Objective hypoxemia thresholds: Measured arterial PO2 or oxygen saturation meeting qualifying values (document exact values on the CMN).

Higher-flow requirement: If prescribed flow >4 LPM, recent test results obtained while the patient was on 4 LPM must be provided (ABG PO2 or oxygen saturation on 4 LPM).>4 LPM

Policy Summary

PayerHighmark Delaware

PolicyHome oxygen therapy (Certificate of Medical Necessity)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDocument a typed office note and a room-air ABG or oxygen saturation within 30 days, include equipment requested and highest ordered flow; if >4 LPM provide test results on 4 LPM.

SourceLink

On This Page

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Borderline qualification (PO2 56-59 mm Hg or O2 sat >=89%): When PO2 is 56-59 mm Hg or oxygen saturation is >=89%, at least one qualifying condition must be documented: dependent edema due to CHF; cor pulmonale or pulmonary hypertension (with diagnostic testing documented); hematocrit >56%; or other specified condition.PO2 56-59 mm Hg or O2 sat >=89%

Alternative treatments: Documentation that alternative measures to improve cardiopulmonary function were considered/tried and were ineffective.

Tests used to establish chronic need for home oxygen must be performed when the patient is in a chronic stable state and not during an acute illness. Documentation on the CMN includes an explicit confirmation that the patient was stable at the time the ABG or oxygen saturation was obtained (question asking “Was patient in a chronic stable state at time ABG or saturation performed? (Not during an acute illness)?”).

The date and results of the most recent assessment of oxygen carrying capacity (ABG PO2 or oxygen saturation) must be documented and the test must have been performed on room air within 30 days of the request. The CMN specifically requests the date of the most recent assessment and records for Arterial Blood Gas PO2 and Oxygen Saturation Test, and asks whether alternative treatments to improve cardiopulmonary function were considered/tried and documented as ineffective.

Testing, Thresholds, and Coding Considerations

Testing and flow thresholds — key facts

Timing and condition of testABG or oxygen saturation must be performed on room air within 30 days of the request

Objective thresholds prompting further evaluationMeasured PO2 of 56-59 mm Hg or oxygen saturation >= 89% triggers documentation of qualifying conditions

High-flow testing requirementIf prescribed flow >4 LPM, provide recent test results obtained while the patient was on 4 LPM (PO2 or O2 saturation)

Documentation to record with testRecord date of test, test type (ABG PO2 or oxygen saturation), test conditions (at rest, during activity, during sleep) and name of provider performing test

Provider Documentation and Actions Required

Documentation Required

Equipment and flow documentation

Provider must specify the type of equipment requested (stationary, portable, or both) and the highest flow (LPM) ordered. If an LPM > 4 is prescribed, include recent test results obtained while the patient was receiving 4 LPM (date of test, ABG PO2 on 4 LPM and/or oxygen saturation on 4 LPM).

Specify equipment requested: Stationary Only, Portable Only, or Both (include mobility status if portable).
Document highest flow (LPM) ordered. If >4 LPM, include test results performed while on 4 LPM: date, Arterial Blood Gas PO2 (mm Hg) and/or Oxygen Saturation (%).

Denial Risk

Timely and proper testing

ABG (PO2) or oxygen saturation measurement must be performed on room air and documented within 30 days of the request. The date of the most recent assessment must be recorded. Tests not done on room air or older than 30 days may lead to denial.

Record date of most recent assessment of oxygen carrying capacity (ABG or % Sat).
Test must be performed on room air and within 30 days of the request.
State whether test was at rest, during exertion, or during sleep; and whether patient was in a chronic stable state at time of testing.

Denial Risk

Missing high‑flow test results

If the provider prescribes >4 LPM but fails to supply recent test results taken while the patient was on 4 LPM, the request may be denied or approved only for flows supported by documentation. Include the required 4 LPM test date and results to avoid denial.

If highest ordered flow >4 LPM, include test date and results while on 4 LPM: ABG PO2 (mm Hg) and/or Oxygen Saturation (%).
Absence of 4 LPM test results may result in denial or approval at a lower flow.

Documentation Required

Alternative treatments considered

Document that alternative treatment measures to improve cardiopulmonary function were considered, tried, and found ineffective when applicable. This must be clearly stated in the office note or CMN.

State whether alternative treatments were considered/tried and document outcomes.
Provide supporting clinical rationale in the typed office note and include lab results if available.

Definitions and Qualifying Conditions

Stable chronic state

DefinitionTest (ABG or oxygen saturation) should be performed when the patient is in a chronic stable state (not during an acute illness)

Documentation requirementCMN asks: 'Was patient in a chronic stable state at time ABG or saturation performed? (Not during an acute illness)?' (Yes/No)

Unacceptable testsTests performed during an acute illness are not acceptable for establishing chronic oxygen need

Qualifying comorbid conditions

Qualifying comorbid conditionsDependent edema due to congestive heart failure

Qualifying comorbid conditionsCor pulmonale or pulmonary hypertension (document diagnostic testing)

Qualifying comorbid conditionsHematocrit greater than 56%

Use when borderline hypoxemiaThese conditions may help qualify patients with PO2 56-59 mm Hg or O2 saturation >=89%

Background

Oxygen therapy is intended to treat patients with chronic hypoxemia to improve tissue oxygenation. Assessment for home oxygen requires objective measurement of arterial oxygen tension (PO2) or oxygen saturation performed on room air, with the result and test date documented on the CMN. The form also requires documentation that disease severity supports therapy, that alternative measures were considered, and identification of test conditions (rest, activity, exercise, or sleep) and the provider who performed the test.