Aetna considers oxygen for home use medically necessary durable medical equipment (DME) in the following circumstances:
Diagnosis of severe lung disease and qualifying lab values:**
Chronic obstructive pulmonary disease (COPD)
Diffuse interstitial lung disease
Pediatric broncho-pulmonary dysplasia (BPD)
Widespread pulmonary neoplasm;
Diagnosis of other hypoxia-related symptoms or findings with qualifying lab values:**
Erythrocytosis (hematocrit greater than 55 %)
Recurring congestive heart failure due to chronic cor-pulmonale;
Other diagnoses of hypoxia-related symptoms or findings with qualifying lab values** that usually resolve with limited or short-term oxygen therapy:
Although treatment of these diagnoses (pneumonia, asthma, croup, bronchitis) may be considered medically necessary for short-term therapy (generally less than 1 month duration), it is not considered medically necessary on an ongoing basis absent special circumstances. Requests for more than episodic oxygen for these diagnoses are subject to medical review. For ongoing oxygen treatment, repeat qualifying lab values are reviewed on a monthly basis.
Other diagnoses for which short-term use of oxygen has been shown to be beneficial (unrelated to hypoxia), e.g., cluster headaches may be certified as medically necessary on an individual case basis upon medical review:
Hemoglobinopathies. Self-administration of adjunctive short-term oxygen therapy in the outpatient setting has been shown to be beneficial and reduce hospitalizations in individuals with hemoglobinopathies, such as hemoglobin sickle cell disease, during vaso-occlusive crisis exacerbated by hypoxia
Infants with BPD may have variable oxygen needs, thus, consideration on a case-by-case basis may be required in the absence of documentation of otherwise qualifying oxygen saturation values.
Oxygen for home use is considered experimental and investigational for indications other than those noted above (e.g., migraine headaches) because its effectiveness for indications other than the ones listed above has not been established.
**Qualifying laboratory values:
Resting PaO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal to 88 %
Resting PaO2 of 56 to 59 mm Hg or oxygen saturation of 89 % in the presence of any of the following
P pulmonale on the electrocardiogram (P wave greater than 3 mm in standard leads II, III, or aVF)
Resting PaO2 greater than 59 mm Hg or oxygen saturation greater than 89 % only with additional documentation justifying the oxygen prescription and a summary of more conservative therapy that has failed.
Non-continuous Oxygen: (oxygen flow rate and number of hours per day must be specified)
During exercise: PaO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal to 88 % with a low level of exertion
During sleep: PaO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal to 88 % with associated complications, such as pulmonary hypertension, daytime somnolence, and cardiac arrhythmias.
Note: All qualification studies must be done while on room air unless medically contraindicated. Documentation of blood gas values can come from the doctor's office, hospital or from an outpatient laboratory.
Oxygen Delivery Systems
The following delivery systems may be considered medically necessary:
Stationary: Oxygen concentrators, liquid reservoirs, or large cylinders (usually K or H size) that are designed for stationary use.
Considered medically necessary for members who do not regularly go beyond the limits of a stationary oxygen delivery system with a 50-ft tubing or those who use oxygen only during sleep.
Portable: Systems that weigh 10 lbs or more and are designed to be transported but not easily carried by the member, e.g., a steel cylinder attached to wheels (“stroller”).
Considered medically necessary for members who occasionally go beyond the limits of a stationary oxygen delivery system with 50-ft tubing for less than 2 hours per day for most days of the week (minimum 2 hours/week).
Ambulatory: Systems that weigh less than 10 lbs when filled with oxygen, are designed to be carried by the member, and will last for 4 hours at a flow equivalent to 2 L/min continuous flow; e.g., liquid refillable units and aluminum or fiber wrapped light-weight cylinders, with or without oxygen conserving devices.
Considered medically necessary for members who regularly go beyond the limits of a stationary oxygen delivery system with a 50-ft tubing for 2 hours or more per day and for most days of the week (minimum 6 hours/week).
Prescription based on the activity status of the member, the appropriate oxygen delivery system will be delivered.
Portable Oxygen Concentrators: Portable oxygen concentrators and combination stationary/portable oxygen systems are considered medically necessary as an alternative to ambulatory oxygen systems for members who meet both of the following criteria:
Member meets criteria for ambulatory oxygen systems (see above); and
Member is regularly (at least monthly) away from home for durations that exceed the capacity of ambulatory oxygen systems.
A second oxygen tank (spare tank) is considered not medically necessary, except in instances where the member is dependent on continuous oxygen. A single oxygen tank may be considered medically necessary for a person who is dependent on an oxygen concentrator.
Emergency or standby oxygen systems are considered not medically necessary.
Duplicate oxygen systems are considered convenience items and not medically necessary, including but not limited to: provision of both a stationary (E1390) and portable (E1392) oxygen concentrator; or provision of both an oxygen transfilling systems and a portable oxygen system (e.g., E0433 with E0434; and, K0738 with E0431).
Notes: Electrical generators do not meet Aetna's definition of DME because they are not primarily medical in nature.
Humidifiers (e.g., Vapotherm) for oxygen nasal cannula are not separately reimbursable.
Rental versus purchase: Aetna considers the rental or, if less costly, purchase of oxygen equipment medically necessary when selection criteria are met.
The reasonable useful lifetime for oxygen equipment is 5 years. The RUL is not based on the chronological age of the equipment. It starts on the initial date of service and runs for 5 years from that date.
Ambulatory oxygen systems and portable oxygen concentrators are considered not medically necessary for members who qualify for oxygen solely based on blood gas studies obtained during sleep.
Note: Except as noted in short-term cases (see 1C above), re-assessment of oxygen needs through pulse oximetry or arterial blood gas is required and must be performed by an independent respiratory provider at 12 months after the initiation of therapy for persons who qualify for oxygen based upon an arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 %, or at 3 months after initiation for persons who qualify for oxygen based upon an arterial PO2 between 56 to 59 mm Hg or an arterial oxygen saturation of 89 % with dependent edema, P pulmonale, or erythrocythemia. Additional re-assessments may be requested at any time at the discretion of Aetna. Re-assessments must be done by an Aetna participating oxygen-qualifying company that is in no way connected to the company supplying the oxygen therapy (as per Medicare guidelines). The member's primary care and/or treating doctor must be notified for authorization of all testing and treatment changes, including the discontinuation of coverage for oxygen therapy.
Aetna considers rental of airline oxygen tank medically necessary when members meet the criteria for oxygen for home use listed above and they are not allowed to use their own portable oxygen tank on the plane.
Note: This policy applies to all products with coverage for DME. Under plans that do not cover DME, domiciliary oxygen may be covered on a case-by-case basis subject to medical review to avert hospital confinement.
This policy is supported by criteria from the Centers for Medicare & Medicaid Services (CMS).
In a Cochrane review, Bennett et al (2008) evaluated the safety and effectiveness of hyperbaric oxygen therapy (HBOT) and normobaric oxygen therapy (NBOT) for treating and preventing migraine and cluster headaches. These investigators searched the following in May 2008: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM and reference lists from relevant articles. Relevant journals were hand-searched and researchers contacted. Randomized trials comparing HBOT or NBOT with one another, other active therapies, placebo (sham) interventions or no treatment in patients with migraine or cluster headache were selected for analysis. Three reviewers independently evaluated study quality and extracted data. A total of 9 small trials involving 201 participants were included; 5 trials compared HBOT versus sham therapy for acute migraine, 2 compared HBOT to sham therapy for cluster headache and 2 evaluated NBOT for cluster headache. Pooling of data from 3 trials suggested that HBOT was effective in relieving migraine headaches compared to sham therapy (relative risk (RR) 5.97, 95 % confidence interval (CI): 1.46 to 24.38, p = 0.01). There was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting or reduce the requirement for rescue medication. There was a trend to better outcome in a single trial evaluating HBOT for the termination of cluster headache (RR 11.38, 95 % CI: 0.77 to 167.85, p = 0.08), but this trial had low power. NBOT was effective in terminating cluster headache compared to sham in a single small study (RR 7.88, 95 % CI: 1.13 to 54.66, p = 0.04), but not superior to ergotamine administration in another small trial (RR 1.17, 95 % CI: 0.94 to 1.46, p = 0.16). Seventy-six per cent of patients responded to NBOT in these 2 trials. No serious adverse effects of HBOT or NBOT were reported. The authors concluded that there was some evidence that HBOT was effective for the termination of acute migraine in an unselected population, and weak evidence that NBOT was similarly effective in cluster headache. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. NBOT is cheap, safe and easy to apply, so will probably continue to be used despite the limited evidence in this review.
The National Institute for Health and Clinical Excellence (NICE)’s guideline on “Diagnosis and management of headaches in young people and adults” (2012) recommended oxygen therapy for cluster headaches; but did not mention its use for migraines.
Jurgens et al (2013) noted that while inhalation of high-flow 100 % oxygen is highly effective in cluster headache, studies on its efficacy in migraine are sparse and controversial. These researchers reported the case of a 22-year old patient with an 8-year history of strictly unilateral migraine without aura but cranial autonomic symptoms. She repeatedly responded completely to inhalation of high-flow pure oxygen within 15 mins but suffered from recurrence of attacks within 30 mins after discontinuation. The authors concluded that in line with experimental animal studies, this case suggested a clinically relevant efficacy of inhaled oxygen in patients with migraine with accompanying cranial autonomic symptoms.
Furthermore, UpToDate reviews on “Acute treatment of migraine in adults” (Bajwa and Sabahat, 2013a) and “Preventive treatment of migraine in adults” (Bajwa and Sabahat, 2013b) do not mention the use of oxygen as a management tool.
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
82803 - 82810
94010 - 94777
HCPCS codes covered if selection criteria are met:
Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing
Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
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 content gauge
Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
Portable liquid oxygen system purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor
Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), 1 month's supply = 1 unit
Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), 1 month's supply = 1 unit
Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), 1 month's supply = 1 unit
Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), 1 month's supply = 1 unit
Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each
Portable oxygen concentrator, rental
Oxygen and water vapor enriching system with heated delivery
Oxygen and water vapor enriching system without heated delivery
Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing
Portable gaseous oxygen system, rental, includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing, for cluster headaches
Oxygen contents, gaseous, 1 unit equals 1 cubic foot
Oxygen contents, liquid, 1 unit equals 1 pound
Other HCPCS codes related to the CPB:
Battery, heavy-duty; replacement for patient-owned ventilator
Battery cables; replacement for patient-owned ventilator
Battery charger; replacement for patient-owned ventilator
Tubing (oxygen), per foot
Variable concentration mask
Water chamber for humidifier, used with positive airway pressure device, replacement, each
Oximeter device for measuring blood oxygen levels non-invasively
Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
Oxygen tent, excluding croup or pediatric tents
Chest shell (cuirass)
Negative pressure ventilator; portable or stationary
Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g. mask)
Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
Pressure support ventilator with volume control mode, may include pressure control mode, used with noninvasive interface (e.g., mask)
Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source
Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery
Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery
Humidifier, non-heated, used with positive airway pressure device
Humidifier, heated, used with positive airway pressure device
Oxygen accessory, flow regulator capable of positive inspiratory pressure
Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each
Oxygen accessory, battery pack / cartridge for portable concentrator, any type, replacement only, each
Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each
Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each
ICD-9 codes covered if selection criteria are met (not all-inclusive):
162.2 - 162.9
Malignant neoplasm of bronchus and lung
Secondary malignant neoplasm of lung
207.00 - 207.12
Acute or chronic erythremia
Benign neoplasm of bronchus and lung
Carcinoma in situ of bronchus and lung
277.00 - 277.09
282.41 - 282.49
282.60 - 282.69
339.00 - 339.02
Acute cor pulmonale
416.0 - 416.9
Chronic pulmonary heart disease
427.0 - 427.9
Congestive heart failure, unspecified
480.0 - 486
490 - 491.8
493.00 - 493.92
494.0 - 494.1
Chronic airway obstruction, not elsewhere classified
Postinflammatory pulmonary fibrosis
Persistent fetal circulation
Chronic respiratory disease arising in the perinatal period
Supplemental oxygen status
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
346.00 - 346.93
Other ICD-9 codes related to the CPB:
Other dyspnea and respiratory abnormalities
The above policy is based on the following references:
Petty TL, O'Donohue WJ Jr. Further recommendations for prescribing, reimbursement, technology development, and research in long-term oxygen therapy. Summary of the Fourth Oxygen Consensus Conference, Washington, DC, October 15-16, 1993. Am Respir Critl Care Med. 1994;150(3):875-877.
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Services (CMS). Evidence of medical necessity for home oxygen therapy. Medicare Carriers Manual §3312. Baltimore, MD: CMS; 2002.
Sanchez Agudo L, Cornudella R, Estopa Miro R, et al. Guidelines for indications and use of domiciliary continuous oxygen (DCO) therapy. SEPAR guidelines. Arch Bronconeumol. 1998;34(2):87-94.
O'Donohue WJ Jr. Home oxygen therapy. Clin Chest Med. 1997;18(3):535-545.
O'Donohue WJ Jr. Home oxygen therapy. Med Clin North Am. 1996;80(3):611-622.
Dunne PJ. The demographics and economics of long-term oxygen therapy. Respir Care. 2000;45(2):223-228; discussion 228-230.
O'Donohue WJ Jr, Bowman TJ. Hypoxemia during sleep in patients with chronic obstructive pulmonary disease: Significance, detection, and effects of therapy. Respir Care. 2000;45(2):188-191; discussion 192-193.
Kotecha S, Allen J. Oxygen therapy for infants with chronic lung disease. Arch Dis Child Fetal Neonatal Ed. 2002;87(1):F11-F14.
Banken R. Home oxygen therapy for the treatment of cluster headache. AETMIS 02-01 NE. Montreal, QC: Agence d'Evaluation des Technologies et des Modes d'Intervention en Sante (AETMIS); 2002.
Gracey K, Talbot D, Lankford R, Dodge P. The changing face of bronchopulmonary dysplasia: Part 2. Discharging an infant home on oxygen. Adv Neonatal Care. 2003;3(2):88-98.
Agence D'Evaluation des Technologies et des Modes D'Intervention en Sante (AETMIS). Portable oxygen therapy for COPD. Hospital Technology at Home. AETMIS 04-03. Montreal, QC; AETMIS; July 2004.
Lau J, Chew P, Wang C, White A. Long term oxygen therapy for severe COPD. Prepared for AHRQ by Tufts-New England Medical Center Evidence-Based Practice Center under Contract No. 290-02-0022. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); June 11, 2004.
Lacasse Y, Lecours R, Pelletier C, Begin R, Maltais F. Randomised trial of ambulatory oxygen in oxygen-dependent COPD. Eur Respir J. 2005;25(6):1032-1038.
Bradley JM, O'Neill B. Short term ambulatory oxygen for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(2):CD004356.
McDonald CF, Crockett AJ, Young IH. Adult domiciliary oxygen therapy. Position statement of the Thoracic Society of Australia and New Zealand. Med J Aust. 2005;182(12):621-626.
Ait-Khaled N, Enarson DA. Managing acute attacks of asthma. Int J Tuberc Lung Dis. 2006;10(5):484-489.
Greenough A. Bronchopulmonary dysplasia--long term follow up. Paediatr Respir Rev. 2006;7 Suppl 1:S189-S191.
Austin M, Wood-Baker R. Oxygen therapy in the pre-hospital setting for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006;(3):CD005534.
Nonoyama ML, Brooks D, Lacasse Y, et al. Oxygen therapy during exercise training in chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007;(2):CD005372.
Say L, Gülmezoglu AM, Hofmeyr GJ. Maternal oxygen administration for suspected impaired fetal growth. Cochrane Database Syst Rev. 2005;(1):CD000137.
Bradley JM, Lasserson T, Elborn S, et al. A systematic review of randomized controlled trials examining the short-term benefit of ambulatory oxygen in COPD. Chest. 2007;131(1):278-285.
American Association of Respiratory Care (AARC). AARC clinical practice guideline. Oxygen therapy in the home or alternate site health care facility--2007 revision & update. Respir Care. 2007;52(8):1063-1068.
Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008;(3):CD004769.
Thoracic Society of Australia and New Zealand, Fitzgerald DA, Massie RJ, Nixon GM, et al. Infants with chronic neonatal lung disease: Recommendations for the use of home oxygen therapy. Med J Aust. 2008;189(10):578-582.
Balfour-Lynn IM. Domiciliary oxygen for children. Pediatr Clin North Am. 2009;56(1):275-296, xiii.
Van Meerhaeghe A, Annemans L, Haentjens P, et al. Home oxygen therapy. KCE Reports 156C. Brussels, Belgium: Belgian Health Care Knowledge Centre (KCE); 2011.
NHIC, Corp. Local coverage article for oxygen and oxygen equipment. Policy Article A33768. Durable Medical Equipment Medicare Administrative Contactor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised October 2012.
NHIC, Corp. Local coverage determination for oxygen and oxygen equipment (L11468). Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised January 1, 2013.
Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database Syst Rev. 2008;(3):CD005219.
Jurgens TP, Schulte LH, May A. Oxygen treatment is effective in migraine with autonomic symptoms. Cephalalgia. 2013;33(1):65-67.
Bajwa ZH, Sabahat A. Acute treatment of migraine in adults. Last reviewed November 2013a. UpToDate Inc., Waltham, MA.
Bajwa ZH, Sabahat A. Preventive treatment of migraine in adults. Last reviewed November 2013b. UpToDate Inc., Waltham, MA.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.