Home oxygen therapy is the home administration of oxygen at concentrations greater than the ambient air with the intention of treating or preventing the symptoms and manifestations of hypoxemic or non-hypoxemic medical conditions that are known to clinically improve with oxygen.

Medically Necessary:

Short term supplemental home oxygen therapy is medically necessary for treatment of hypoxemia-related symptoms with qualifying laboratory values (see Note below) associated with acute conditions such as, but not limited to:

• Bronchiolitis
• Chronic obstructive pulmonary disease exacerbation
• Pneumonia

Long term supplemental home oxygen therapy is medically necessary for treatment of hypoxemia-related symptoms with qualifying laboratory values (see Note below) from chronic lung conditions such as, but not limited to:

• Bronchiectasis
• Chronic lung disease (CLD) (formerly named Bronchopulmonary Dysplasia [BPD])
• Chronic obstructive pulmonary disease
• Cystic fibrosis
• Diffuse interstitial lung disease
• Pulmonary hypertension
• Pulmonary neoplasm (primary or metastatic)
• Recurring congestive heart failure due to chronic cor pulmonale

Intermittent home oxygen therapy is considered medically necessary for the treatment of cluster headaches.

Supplemental home oxygen therapy is considered medically necessary during exercise when there is documentation of:

• Desaturation to an arterial oxygen saturation (SaO₂) of equal to or less than 88% during exercise; and
• Improvement in hypoxemia and dyspnea or exercise capacity during exercise while using supplemental oxygen.

Supplemental home oxygen therapy is considered medically necessary during sleep in individuals:

• With unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure, or erythrocytosis with a hematocrit of greater than 56%; or

• When obstructive sleep apnea (OSA), other nocturnal apnea, or hypoventilation syndromes have been ruled out and desaturation during sleep to an SaO₂ of equal to or less than 88% for greater than 30% of the night is documented; or
• When individuals diagnosed with OSA, other nocturnal apnea, or hypoventilation syndromes have desaturation during sleep to an SaO₂ of equal to or less than 88% for greater than 30% of the night which persists despite use of continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV) devices.

Note: Hypoxemia is evidenced by any of the qualifying laboratory values obtained while breathing room (ambient) air unless contraindicated:

Adults:

1. Arterial partial pressure of oxygen (PaO₂) equal to or less than 55 mm Hg or SaO₂ equal to or less than 88%; or
2. Arterial PaO₂ of 56-59 mm Hg or SaO₂ equal to or less than 89% with any of the following conditions:
   • Cor pulmonale
   • Dependent edema secondary to right heart failure
   • Erythrocytosis with hematocrit greater than 56%
   • Pulmonary hypertension

Infants and Children:

1. PaO₂ of equal to or less than 60 mm Hg; or
2. SaO₂ of equal to or less than 92%.

Not Medically Necessary: 

Home oxygen therapy is considered not medically necessary for any of the following indications, including but not limited to:

• Severe peripheral vascular disease with clinically evident desaturation in one or more extremities in the absence of hypoxemia
• Terminal illness not affecting the respiratory system
• Treatment of angina pectoris or dyspnea in the absence of documented associated cor pulmonale or hypoxemia
• The use of preset regulators used with portable oxygen systems

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Home oxygen therapy is the home administration of oxygen at concentrations greater than the ambient air with the intention of treating or preventing the symptoms and manifestations of hypoxemic or non-hypoxemic medical conditions that are known to clinically improve with oxygen.

Arterial oxygen saturation of hemoglobin (SaO₂) can be measured by arterial blood gas (ABG) sampling or pulse oximetry. The healthcare practitioner orders the testing type and frequency. Normal values of SaO₂ are 94% to 100%.

For the diagnosis of cluster headache, oxygen inhalation (100%) delivered at a rate of 7 to 10L/min. for 15 minutes through a loose-fitting facemask is considered to be a safe and effective, first-line treatment for acute attacks. High-flow oxygen has been shown to abort the headache within several minutes.

Oxygen equipment alternatives include three types of systems to provide home oxygen:

• Compressed oxygen (tanks)
• Liquid oxygen
• Oxygen concentrators

With all of these systems, oxygen is inhaled through a mask or more commonly, a nasal cannula. Oxygen conserving devices can be used with compressed or liquid oxygen. The most popular oxygen conserving devices are demand inspiratory flow systems. These devices use a sensor to detect when inspiration begins and deliver oxygen only during inspiration, thus conserving oxygen during exhalation.

Peer Reviewed Publications:

1. Bailey RE. Home oxygen therapy for treatment of patients with chronic obstructive pulmonary disease. Am Fam Physician. 2004; 70(5):864-865.
2. Beck E, Sieber WJ, Trejo R. Management of cluster headache. Am Fam Physician. 2005; 71(4):717-724.
3. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009; 302(22):2451-2457.
4. Dodick DW, Capobianco DJ. Treatment and management of cluster headache. Curr Pain Headache Rep. 2001; 5(1):83-91.
5. Fussell KM, Ayo DS, Branca P, et al. Assessing need for long-term oxygen therapy: a comparison of conventional evaluation and measures of ambulatory oximetry monitoring. Respir Care. 2003; 48(2):115-119.
6. Hess D. Detection and monitoring of hypoxemia and oxygen therapy. Respir Care. 2000; 45(1):65-80.
7. Kacmarek RM. Delivery systems for long-term oxygen therapy. Respir Care. 2000; 45(1):84-92.
8. MacLean JE, Fitzgerald DA. A rational approach to home oxygen use in infants and children. Paediatric Respir Rev. 2006; 7(3): 215-222.
9. Matharu M, Silver N. Cluster headache. Clin Evid (Online). 2008; pii: 1212.
10. Tarpy SP, Celli BR. Long-term oxygen therapy. NEJM. 1995; 333(11):710-714.
11. Tie SW, Hall GL, Peter S, et al. Home oxygen for children with acute bronchiolitis. Arch Dis Child. 2009; 94(8):641-643.
12. Uronis HE, Currow DC, McCrory DC, et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer. 2008; 98(2):294-299.
13. Wilt TJ, Niewoehner D, MacDonald R, Kane RL. Management of stable chronic obstructive pulmonary disease: a systematic review for a clinical practice guideline. Ann Intern Med. 2007; 147(9):639-653.
14. Zielinski J. Long-term oxygen therapy in conditions other than chronic obstructive pulmonary disease. Respir Care. 2000; 45(2):172-176.

Government Agency, Medical Society, and other Authoritative Publications:

1. American Association for Respiratory Care (AARC). Clinical Practice Guideline. Oxygen therapy in the home or alternative site health care facility. Respir Care. 2007; 52(1):1063-1068.
2. American Association for Respiratory Care (AARC). Clinical Practice Guideline. Selection of an oxygen delivery device for neonatal and pediatric patients: 2002 revision and update. Respir Care. 2002; 47(6):707-716.
3. American Thoracic Society/European Respiratory Society Task Force. Standards for the diagnosis and management of patients with COPD. Version 1.2. New York: American Thoracic Society; 2004 [updated 2005 September 8]. Available at: http://www.thoracic.org/clinical/copd-guidelines/resources/copddoc.pdf. Accessed on August 30, 2011.
4. Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2007; 131(6):1917-1928.
5. Balfour-Lynn IM, Field DJ, Gringras P, et al. British Thoracic Society (BTS) guidelines for home oxygen in children. Thorax. 2009; 64 (2):ii1-26.
6. Bradley JM, O'Neill B. Short-term ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005; (4):CD004356.
7. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Home use of oxygen. NCD #240.2. Effective October 27, 1993. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on August 30, 2011.
8. Cranston JM, Crockett AJ, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008; (3):CD004769.
9. Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005, (4):CD001744.
10. Croxton TL, Brady WC. Long term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. Am J Resp Crit Care Med. 2006; 174:373-378.
11. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (updated 2010). Available at: http://www.goldcopd.org/.  Accessed on August 30, 2011.
12. May A, Leone M, Afra J, et al. European Federation of Neurological Societies (EFNS) guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol. 2006; 13(10):1066-1077.
13. National Institute for Clinical Excellence (NICE). CG101 Chronic obstructive pulmonary disease: update (full guideline). September 22, 2011. Available at: http://guidance.nice.org.uk/CG101/Guidance/pdf/English. Accessed on November 14, 2011.
14. Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011; 155(3):179-191.  
15. Ram FSF, Wedzicha JA. Ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2002; (1):CD000238.
16. Rozen TD, Fishman RS. Inhaled oxygen and cluster headache sufferers in the United States: use, efficacy and economics: results from the United States Cluster Headache Survey. Headache. 2011; 51(2):191-200.

Home Oxygen Therapy

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