This document addresses the clinical indications for use of home oxygen therapy.

Clinical Indications

Medically Necessary:

1. 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 including, but not limited to any of the following:
   1. Bronchiolitis; or
   2. Chronic obstructive pulmonary disease exacerbation; or
   3. Pneumonia
2. 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 including, but not limited to any of the following:
   1. Bronchiectasis; or
   2. Chronic lung disease; or
   3. Chronic obstructive pulmonary disease; or
   4. Cystic fibrosis; or
   5. Diffuse interstitial lung disease; or
   6. Pulmonary hypertension; or
   7. Pulmonary neoplasm (primary or metastatic); or
   8. Recurring congestive heart failure due to chronic cor pulmonale.
3. Intermittent home oxygen therapy is considered medically necessary for the treatment of cluster headaches.
4. Supplemental home oxygen therapy is considered medically necessary during exercise when there is documentation of both of the following:
   1. Hypoxemia during exercise; and
   2. Improvement in hypoxemia and dyspnea or exercise capacity during exercise while using supplemental oxygen.
5. Supplemental home oxygen therapy is considered medically necessary during sleep in an individual with any of the following conditions:
   1. Unexplained pulmonary hypertension, cor pulmonale, edema secondary to right heart failure, or erythrocytosis and hematocrit is greater than 56%; or
   2. When obstructive sleep apnea, 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 greater than 30% of the night; or
   3. When an individual with documented obstructive sleep apnea, other nocturnal apnea, or a hypoventilation syndrome experiences desaturation during sleep to a SaO₂ of equal to or less than 88% for greater than 30% of the night, which persists despite use of continuous positive airway pressure or non-invasive positive pressure ventilation devices.

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

1. 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:
      1. Cor pulmonale; or
      2. Dependent edema secondary to right heart failure; or
      3. Erythrocytosis with hematocrit greater than 56%; or
      4. Pulmonary hypertension.
2. 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:

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