CurrentKaiser PermanentePolicy No. 03-13

Clinical Review Portable And Liquid Oxygen Ga

Policy defines medical necessity criteria, documentation, covered and noncovered uses, and device-type criteria for home oxygen therapy including stationary, portable, ambulatory, portable oxygen concentrators, and liquid oxygen (not available in GA). Applies to Quality Resource Management review for Georgia region.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Portable And Liquid Oxygen Ga

Policy CodePolicy No. 03-13

Change TypeReviewed/Revised

Effective DateMar 16, 2003

Next Review DateFeb 21, 2025

Key ActionProviders must submit a valid physician prescription including flow rate, frequency/duration of use, duration of need, type and means of delivery, specifics of varying flow rates, and noncontinuous use details when applicable.

SourceLink

POLICY UPDATE CHANGES

Policy last revised 2/21/2024; reviewed/revised.

AnnualFollow-up requirement

6MWT <90%Primary walk-test threshold

HCT >56%Erythrocytosis threshold

Coverage Summary

Overview: This Quality Resource Management (QRM) coverage criteria (Policy No. No. 03-13) addresses medical necessity for Home Oxygen Therapy (portable and liquid oxygen systems). Status: CURRENT. Effective: 2003-03-16; Last review/revision: 2024-02-21. Scope: Defines documentation and clinical criteria QRM will use to determine coverage for stationary, portable, ambulatory, portable oxygen concentrators (POCs), and liquid oxygen (note: liquid oxygen not available in GA). The policy references CMS guidance and Aetna oxygen coverage (CMS Manual 240.2 - Home Use of Oxygen; Aetna CPB - Oxygen) as supporting guidance.

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Medical-Necessity Criteria

Medically Necessary / Initial Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Physician prescription or clinical documentation are required.
ALL of the following
- chronic obstructive pulmonary disease
- diffuse interstitial lung disease
- cystic fibrosis, bronchiectasis
- chronic oxygen dependence
- widespread pulmonary neoplasm
- hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy (e.g., pulmonary hypertension symptoms, recurrent CHF due to chronic cor pulmonale, erythrocytosis HCT > 56%, impairment of cognitive process, nocturnal restlessness, morning headache)
ONE of
- A measurement of arterial PO2 or arterial oxygen saturation obtained by ear or pulse oximetry.
- A greater than normal fall in oxygen level during sleep (decrease in arterial PO2 > 10 mm Hg, or decrease in arterial oxygen saturation > 5 percent) associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cognitive impairment, nocturnal restlessness or insomnia).Decrease in arterial PO2 > 10 mm Hg or decrease in arterial oxygen saturation > 5%
- A pulse ox of < 90% on a 6-minute walk test (6MWT).< 90% on 6MWT
  May be performed by primary care, pulmonology, or oxygen clinic; may be performed virtually.
ALL of the following
- The oxygen flow rate.
- An estimate of frequency, duration of use (e.g., 2 L/min, 10 minutes per hour, 12 hours/day), and duration of need (e.g., 6 months or lifetime).
- The type of oxygen delivery system to be used (gas, liquid, or concentrator).
- The means of oxygen delivery (mask, nasal cannula, etc.).
- Specifics of any varying flow rates.
- Specification if use is noncontinuous as appropriate.

Additional / Ongoing Review Requirements

Requirements for continued coverage and documentation

ALL of the following

New documentation by attending physician must be submitted for revised oxygen requirements after change in patient's condition.
After 36 months the oxygen delivery system does not need review; home O2 supplies may be approved annually (member needs at least 1 annual visit with PCP or pulmonologist).
Patients on chronic oxygen require annual reviews including oxygen saturation with 6-minute walk test, or pulse ox < 89% on room air.Pulse Ox < 89% on room air for annual review
If member misses 2 oxygen clinic appointments for recertification, QRM will send denial letter for continued oxygen due to lack of clinical information; member may self-pay; vendor will not remove oxygen until physician discontinues.

Short-term / Case-by-Case Uses

May be certified as medically necessary on individual case basis when documentation supports benefit:

ANY of the following

Cluster headaches meeting International Headache Society diagnostic criteria and refractory to medications.
Hemoglobinopathies (e.g., sickle cell disease) for adjunctive short-term outpatient oxygen during vaso-occlusive crisis exacerbated by hypoxia.
Infants with bronchopulmonary dysplasia (BPD) on case-by-case basis when oxygen saturation documentation is absent and needs are variable.

Noncovered / Not Medically Necessary Uses

Not covered for the following uses:

ANY of the following

Angina pectoris in the absence of hypoxemia.
Breathlessness without cor pulmonale or evidence of hypoxemia.
Severe peripheral vascular disease with clinically evident desaturation in extremities.
Terminal illnesses that do not affect the lungs.

Portable Oxygen System Coverage

Criteria to qualify for a portable oxygen system in addition to stationary system:

ALL of the following

Patient meets the general oxygen use requirements above.
ALL of the following
- Portable oxygen systems are not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.

Portable Oxygen Concentrator (POC) Coverage

POCs considered medically necessary as an alternative to ambulatory oxygen if ALL conditions met:

ALL of the following

Member meets criteria for ambulatory oxygen systems (see ambulatory criteria below).
AND one of
- Member is regularly (at least monthly) away from home for durations that exceed the capacity of ambulatory oxygen systems.
- Member is on > 2 pulse O2 (or 2 L or more continuous O2).
- Member has severe problems with dexterity and is unable to utilize portable tanks (e.g., documented severe rheumatoid or osteoarthritis).

Device Type Indications (Excerpt from Aetna Guidance)

Device selection based on mobility and duration away from stationary system:

ANY of the following

Stationary concentrator: medically necessary for members who do not regularly go beyond limits of stationary system with 50-ft tubing or who use oxygen only during sleep.
Portable systems (>=10 lbs): medically necessary for members who occasionally go beyond limits of stationary system with 50-ft tubing for less than 2 hours per day for most days of week (minimum 2 hours/week).< 2 hours/day; minimum 2 hours/week
Ambulatory systems (<10 lbs): medically necessary for members who regularly go beyond limits of stationary system with 50-ft tubing for 2 hours or more per day for most days of week (minimum 6 hours/week). Prescription based on activity status.>= 2 hours/day; minimum 6 hours/week

Provider Actions

Prior Authorization

Submit physician prescription and documentation

Include a valid physician prescription that specifies all required elements to authorize home oxygen: the oxygen flow rate; an estimate of frequency and duration of use and the expected duration of need; the type of oxygen delivery system (gas, liquid, or concentrator); the means of delivery (mask, nasal cannula, etc.); specifics of any varying flow rates; and whether use is noncontinuous when applicable.

Flow rate
Frequency and duration of use (e.g., 2 L/min, 10 minutes per hour, 12 hours/day)
Duration of need (e.g., 6 months or lifetime)
Type of delivery system (gas, liquid, concentrator)
Means of delivery (mask, nasal cannula, etc.)
Specifics of any varying flow rates
Specification if use is noncontinuous

Documentation Required

Provide hypoxia measurements

Provide objective evidence of hypoxia using ONE of the following measurements to support medical necessity: arterial PO2 or arterial oxygen saturation (by arterial blood gas, ear, or pulse oximetry); a sleep-related fall in oxygen (decrease in arterial PO2 > 10 mm Hg or decrease in arterial oxygen saturation > 5%) associated with symptoms attributable to hypoxemia; or a 6-minute walk test with pulse oximetry showing pulse oximetry < 90%. Testing may be performed by primary care, pulmonology, or the oxygen clinic and may be performed virtually where indicated.

Arterial PO2 or arterial oxygen saturation (ear or pulse oximetry)
Sleep-related fall in PO2 (>10 mm Hg) or O2 saturation (>5%) with associated symptoms
6-minute walk test with pulse oximetry < 90%

Documentation Required

Annual recertification and clinic attendance

Chronic oxygen users require ongoing documentation and clinic follow-up. Submit new physician documentation when oxygen requirements change. After 36 months the delivery system typically does not require review, but home O2 supplies may be approved annually. Members need at least one annual visit with a primary care provider or pulmonologist and annual reviews that include oxygen saturation assessment (6MWT or pulse oximetry). If a member misses two oxygen clinic appointments for recertification, QRM will send a denial letter for continued oxygen due to lack of clinical information; the member may self-pay and oxygen will not be removed until a physician discontinues it.

Submit new attending physician documentation for changes in condition
At least 1 annual visit with PCP or pulmonologist required
Annual reviews to include oxygen saturation with 6MWT or pulse ox
Missing 2 recertification appointments may trigger QRM denial; member may self-pay

Billing Rule

Duplicate systems not covered

Spare, emergency/standby, or duplicate portable oxygen systems are generally not medically necessary and are considered convenience items. Duplicate portable systems are not covered in conjunction with another portable system; vendors and payers restrict coverage for additional portable oxygen equipment.

E0433
E0434
E0431
K0738

Denial Risk

POC for travel not covered

Portable oxygen concentrators provided solely for travel are considered convenience items and are not a covered benefit.

E1390	Stationary oxygen concentrator
E1399	Unlisted oxygen equipment supply
E0424	Portable gaseous oxygen system, rental
E0425	Portable gaseous oxygen system, purchase
E0430	Liquid oxygen portable system, single unit
E0431	Liquid oxygen portable system, additional/alternate
E0433	Oxygen conserving device, portable
E0434	Oxygen conserving device, other
E0435	Oxygen system, gaseous, portable
E0439	Portable oxygen concentrator

OpenPayer

Clinical Review Portable And Liquid Oxygen Ga

Coverage Summary

Medical-Necessity Criteria

Coding

Provider Actions

Background & Definitions

Revision History

E0433	Portable oxygen conserving device (duplicate portable systems not covered with another portable system)
E0434	Oxygen conserving device (see duplication guidance)
E0431	Liquid oxygen portable system (duplicate portable coverage restrictions)
K0738	Portable oxygen equipment (referenced as duplicate with E0431)