HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
E-19-019
Topic:
Oxygen
Section:
Durable Medical Equipment
Effective Date:
November 20, 2022
Issued Date:
November 20, 2022
Last Revision Date:
November 2022
Annual Review:
February 2022
 
 

Oxygen is administered by devices that provide controlled oxygen concentrations and flow rates. Oxygen therapy should maintain adequate tissue and cell oxygenation while avoiding oxygen toxicity. 

Policy Position

Oxygen and oxygen supplies may be considered medically necessary for appropriately selected individuals only in cases when oxygen is prescribed by a physician. The prescription must specify:

  • A diagnosis of the disease requiring use of oxygen; and
  • Oxygen concentration and flow rate; and
  • Frequency of use (if an intermittent or leave in oxygen therapy, order must include time limits and specific indications for initiating and terminating therapy); and
  • Method of delivery; and
  • Duration of use (if the oxygen is prescribed on an indefinite basis, care must be periodically reviewed to determine whether a medical need continues to exist).

Oxygen therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

A4606 

A4608

A4615

A4616

A4617

A4619

A4620

E0424

E0425

E0439

E0440

E0441

E0442

E0447

E0455

E0550

E0555

E0560

E1352

E1353

E1354

E1355

E1356

E1357

E1358

E1390

E1391

E1392

E1399

E1405

E1406   

 

 

 

 


Oxygen therapy may be considered medically necessary for ANY of the following:

  • Cluster headaches; or
  • Severe lung disease, defined as either: a resting arterial oxygen partial pressure (PaO2) below 55 mm Hg; or O2 saturation less than 90%; or symptoms associated with oxygen deprivation, (e.g., impairment of cognitive processes, restlessness, or insomnia). Examples of severe lung disease include, but are not limited to:
    • Chronic obstructive pulmonary disease (COPD); or
    • Pulmonary fibrosis; or
    • Cystic fibrosis; or
    • Bronchiectasis; or
    • Bronchiolitis; or
    • Recurring congestive heart failure due to chronic cor pulmonale; or
    • Respiratory Syncytial virus (RSV); or
    • Chronic lung disease complicated by erythrocytosis (hematocrit greater than 56%).

 

E0445

E0580

E0585

E1390

E1392

 

 


Supplemental home oxygen therapy may be considered medically necessary during sleep in an individual with ANY of the following conditions:

  • Unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure, or erythrocytosis and hematocrit is greater than 56%; or
  • When obstructive sleep apnea (OSA), other nocturnal apnea, or a hypoventilation syndrome has been ruled out and there is documentation of desaturation during sleep to an SaO2 of equal to or less than 88% for at least five (5) minutes while asleep; or
  • When an individual with documented OSA, other nocturnal apnea, or a hypoventilation syndrome experiences desaturation during sleep to a SaO2 of equal to or less than 88% for at least five (5) minutes while asleep  which persists despite use of continuous positive airway pressure (CPAP) or non-invasive positive pressure ventilation (NIPPV) devices.

Oxygen therapy is considered not medically necessary for the following conditions:

  • Angina pectoris in the absence of hypoxemia; or
  • Breathlessness without evidence of hypoxemia; or
  • Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or
  • Terminal illnesses that do not affect the lungs.

Portable oxygen systems may be considered medically necessary only if the patient ambulates on a regular basis.

Supplemental home oxygen therapy not meeting the criteria as indicated in this policy is considered not medically necessary.

E0430

E0431

E0433

E0434

E0435

E0443

E0447

E1390

K0738

 

 

 

 

 


The replacement of two (2) reusable probes every 12 months or five (5) disposable oximeter probes every one (1) month may be considered medically necessary when the probe is inoperable due to:

  • Faulty or damaged wiring, sensors, pads, connectors, straps; or
  • Damaged or missing springs; or
  • Broken or missing shells; or
  • Inaccurate data evidenced by environmental factors (e.g., movement or body temperature).

Quantity level limits or quantities of supplies that exceed the frequency guidelines listed in the policy will be denied as not medically necessary.

Note: Modifier RA or RB must be indicated when the replacement is a disposable oximeter probe.

A4606

 

 

 

 

 

 


Place of Service: Outpatient

The use of oxygen and oxygen supplies is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



Links





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association.  Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania.  Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York].  All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.