DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for Home Oxygen Therapy.

Definitions

Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Local Coverage Article (LCA) information, as well as other CMS sources, using the links below.

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement.

Place of Service

The proper place of service for home oxygen therapy is in the home setting.

Coverage Determination and Links

HHO Duals follows the coverage determinations made by CMS as outlined in either the NCD or the state-specific LCD/LCA.

CMS Link

·       CMS Website

NCD/LCD Links

·       NCD: Home Use of Oxygen (240.2)

·       LCD: Oxygen and Oxygen Equipment (L33797)

Related NCD: Home Oxygen Use to Treat Cluster Headache (CH) (240.2.2)

Article Links

LCA: Oxygen and Oxygen Equipment - Policy Article (A52514)

Note: Accessories, including but not limited to, trans-tracheal catheters (A4608), cannulas (A4615), tubing (A4616), mouthpieces (A4617), face tent (A4619), masks (A4620, A7525), oxygen conserving devices (A9900), oxygen tent (E0455), humidifiers (E0555), nebulizer for humidification (E0580), regulators (E1353), and stand/rack (E1355) are included in the allowance for rented oxygen equipment. The supplier must provide any accessory ordered by the treating practitioner.

Only rented oxygen equipment is eligible for coverage under this policy. Purchased oxygen equipment is non-covered.

Oximeters (E0445) and replacement probes (A4606) will be denied as non-covered because they are monitoring devices that provide information to the treating practitioner to assist in managing the patient’s treatment.

Respiratory therapist services are non-covered under the DME benefit.

Reimbursement

Participating facilities ill be reimbursed per their HHO Duals contract.