Home oxygen therapy is most commonly used to treat chronic, stable medical conditions that cause significant hypoxemia, such as severe lung disease (e.g., chronic obstructive pulmonary disease [COPD], interstitial fibrosis, cystic fibrosis, pulmonary neoplasm), pulmonary hypertension, and congestive heart failure related to cor pulmonale. Appropriate evidence of significant hypoxemia includes arterial blood gas studies, pulse oximetry, and certain clinical signs, such as elevated pulmonary artery pressure, dependent edema, and polycythemia vera. Home oxygen therapy may be delivered via nasal cannula, face mask, or transtracheal catheter. Supply sources include a stationary or portable compressed gas tank, stationary or portable liquid oxygen tank, or stationary oxygen concentrator. Our current Medical Policy #05.00.58e: Home Oxygen Therapy will be updated as outlined below, and revised Medical Policy #05.0058f will become effective April 1, 2013. The following policy criteria have been revised:

Group 1 Criteria

Current policy Revised policy (effective April 1, 2013) The individual demonstrates a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5 percent for at least five* minutes during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, P-pulmonale on electrocardiogram [P-wave greater than 3 mm in standard leads II, III, or AVF], documented pulmonary hypertension, polycythemia vera). The individual demonstrates a decrease in arterial PO2 greater than 10 mmHg or a decrease in arterial oxygen saturation greater than 5 percent from baseline for at least five* minutes during sleep that is associated with any of the following signs and symptoms attributable to hypoxemia: Nocturnal restlessness Insomnia Cor pulmonale "P" pulmonale on electrocardiogram (EKG) Documented pulmonary hypertension Erythrocytosis *For all the sleep oximetry criteria described above, the five minutes do not have to be continuous.

Prescription renewal

Current policy Revised policy (effective April 1, 2013) A revised prescription for home oxygen therapy is required in any of the following situations: When the prescribed maximum flow rate changes from one of the following categories to another: Less than 1 LPM 1 – 4 LPM Greater than 4 LPM If the change is from less than 4 LPM to greater than 4 LPM, a repeat blood gas study with the individual on 4 LPM must be performed. If the physician specified less than lifetime length of need on the most recent CMN, and this length of need has expired. When a portable oxygen system is added subsequent to the initial certification of a stationary system. When a stationary system is added subsequent to the initial certification of a portable system. When there is a new treating physician but the oxygen order is the same. A change in a DME provider who does not have the prior prescription. A revised prescription for home oxygen therapy is required in any of the following situations: When the prescribed maximum flow rate changes from one of the following categories to another: Less than 1 LPM 1 – 4 LPM Greater than 4 LPM If the change is from less than 4 LPM to greater than 4 LPM, a repeat blood gas study with the individual on 4 LPM must be performed. A blood gas study must be the most recent study obtained within 30 days prior to the initial date. If the physician specified less than lifetime length of need on the most recent CMN, and this length of need has expired. A blood gas study must be the most recent study obtained within 30 days prior to the initial date. When a portable oxygen system is added subsequent to the initial certification of a stationary system. There is no requirement for a repeat blood gas study unless the initial qualifying study was performed during sleep, in which case a repeat blood gas study must be performed while the beneficiary is at rest (awake) or during exercise within 30 days prior to the revised date. When a stationary system is added subsequent to the initial certification of a portable system. When there is a new treating physician but the oxygen order is the same. A change in a DME provider who does not have the prior prescription. The following policy criteria have been added: Recertification in other scenarios: For replacement equipment, repeat testing is not required. Enter the most recent qualifying value and test date. This test does not have to be within 30 days prior to the initial date. It can be the test reported on the most recent certification. There is no requirement for a physician visit related to the certification for replacement of equipment. Please refer to the Medical Policy section of our AmeriHealth website to view our medical policies. For questions or additional information related to our home oxygen therapy policy, please contact your Network Coordinator or Hospital/Ancillary Services Coordinator.