CurrentKaiser PermanentePolicy KP-0343

Kaiser Foundation Health Plan of Washington Clinical Review Criteria

Clinical review criteria governing medical necessity determinations and coverage for home oxygen therapy and related oxygen equipment for Kaiser Foundation Health Plan of Washington members, referencing Medicare coverage manuals and MCG guidelines for non-Medicare members.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria

Policy CodePolicy KP-0343

Change TypeCode update (03/01/2022)

Effective DateDec 15, 1985

Next Review Date

Key ActionWhen requesting home oxygen, send most recent pulse oximetry and/or at-rest/activity oxygenation log and last 6 months of clinical notes from requesting provider and/or specialists to support the utilization review.

POLICY UPDATE CHANGES

03/01/2022 - Updated applicable codes

>15Listed HCPCS codes

MCG referencedNon-Medicare criteria source

CMS NCD referencedMedicare criteria source

Coverage Summary

This policy (KP-0343) covers clinical review criteria for Home Oxygen and Oxygen Equipment (Home Oxygen) and governs medical necessity determinations and coverage for Kaiser Foundation Health Plan of Washington members. The policy status is CURRENT and the coverage stance is covered_with_criteria. Effective date: 1985-12-15; Last review: 2024-02-13. For Medicare members, coverage follows Medicare sources including the CMS Claims Processing Manual Chapter 20 Section 30.6 and NCD Home-Use of Oxygen (240.2); for non-Medicare members Kaiser Permanente uses the MCG (Milliman Care Guidelines) Home Oxygen guideline as the primary non-Medicare criteria source. Policy number: KP-0343.

Medical-Necessity Criteria

Medicare Members - Coverage Criteria

Covered when ALL of the following Medicare-related criteria and applicable policy statements are met:

Coverage follows CMS Coverage Manuals: Medicare Claims Processing Manual Chapter 20 Section 30.6 (Oxygen and Oxygen Equipment) and the NCD Home-Use of Oxygen (240.2) and related NCAs/LCDs

Medicare policy and local coverage determinations apply

Non-Medicare Members - Coverage Criteria

Covered when ALL of the following are met per MCG Home Oxygen guideline (as adopted by Kaiser Permanente):

Use the Home Oxygen (KP-0343) MCG clinical guideline criteria for medical necessity determinations

MCG proprietary; provider may request criteria on individual case

Provide supporting documentation: most recent pulse oximetry and/or most recent at rest and/or activity oxygenation log

Required for medical necessity review

Provide last 6 months of clinical notes from requesting provider and/or specialist (palliative care, primary care, pulmonary care)

Required for medical necessity review

Coding

Covered HCPCS Codes for Oxygen Equipment and Supplies (considered medically necessary when applicable criteria met)HCPCSCovered

E0424	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator
E0425	Cannula or mask
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, without supply reservoir and contents gauge
E0434	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier
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
E0441	Stationary oxygen contents, gaseous; month's supply, 1 unit

1–10 of 20

1/2

Provider Actions

Documentation Required

Submit supporting documentation for medical necessity

When requesting home oxygen, send documentation to support medical necessity. Required documents include the most recent pulse oximetry and/or most recent at-rest and/or activity oxygenation log, and the last 6 months of clinical notes from the requesting provider and/or relevant specialists.

Most recent pulse oximetry and/or most recent at-rest and/or activity oxygenation log
Last 6 months of clinical notes from requesting provider and/or specialist (palliative care, primary care, pulmonary care)

Prior Authorization

Pre-authorization / Authorization verification

Verify authorization requirements for specific codes and plan types using the Pre-authorization Code Check prior to billing or providing the service.

Background

Kaiser Permanente developed home oxygen clinical review criteria beginning in 1986 after identifying increased use of home oxygen without documented clinical indications and lack of re-testing to verify ongoing need. In 1989 a task force reviewed the literature and adopted the Medicare home oxygen criteria, defined appropriate exceptions, and established testing and re-testing programs. The program was submitted to Medicare, which approved it and adopted several features (including the re-testing program). These criteria have been used to guide utilization review, authorization decisions, and retesting programs; Kaiser also adopted the proprietary MCG Home Oxygen guideline for non-Medicare determinations and requires submission of supporting documentation (pulse oximetry or activity logs and recent clinical notes) for medical necessity review.

MCG: Milliman Care Guidelines — proprietary clinical guideline used by Kaiser Permanente for non-Medicare medical necessity determinations (providers may request the specific MCG criteria used for an individual utilization management decision).

Name	NCD/LCD Number/Type
Home-Use of Oxygen	240.2 / NCD

Revision History

1985-12-15initial_effective

Policy effective date (criteria development began historically; effective date listed as 12/15/1985).

03/01/2022code_update

Updated applicable codes (03/01/2022 code update noted in revision history).

11/01/2022review

Policy review noted (11/01/2022).

11/07/2023review

Policy review noted (11/07/2023).

02/13/2024reviewLatest

Most recent policy review date listed (02/13/2024).