Oscar Oxygen Therapy (CG005) Form

The Plan members who have hypoxemia (abnormally low blood oxygen levels) and meet certain clinical criteria may be eligible for Short-Term Oxygen Therapy (STOT) or Long-Term Oxygen Therapy (LTOT). STOT should be prescribed for hypoxemia in the setting of the acute conditions detailed in the criteria below and, in general, requires frequent reassessment. LTOT should only be prescribed when there is evidence of persistent hypoxemia in a clinically stable patient, who is receiving otherwise optimal medical management, and meets specified clinical criteria. Optimal medical management should include treatment for the underlying condition. Patients who are clinically unstable may require oxygen therapy and be reassessed later for their long-term oxygen needs. Oxygen therapy can be delivered via many different devices, including stationary units, portable or ambulatory equipment, and oxygen conserving devices. The device must be prescribed by a licensed physician or advanced practice provider and supplied by an in-network vendor. Definitions “Pulse Oximetry” is a non-invasive method of obtaining a member’s oxygen saturation by analyzing light absorption of red blood cells in the arteries. “Arterial Blood Gas” is a lab test run on blood collected from an artery that measures the absorbed gases in blood, including oxygen. 1 “Oxygen Carriers” are pieces of equipment used to help a member transport an oxygen delivery system. These are included in the rented system. Oxygen carriers may include but are not limited to: 1. A carrier attached to a wheelchair that is used to carry an oxygen cylinder; or 2. A stand that holds a cylinder that can be moved by the user; or 3. A shoulder bag to hold portable tank. “Oxygen Humidifiers” are bottles filled with water that attach to the oxygen system to create humidity and increase moisture into the user’s airway. These are included in the rental system. “Oxygen Regulators” attach to the oxygen cylinder (green tank) where they are used to adjust the flow of oxygen to deliver the prescribed amount. These are included in the rented system. “Oxygen Concentrators” are stationary or portable devices that extract oxygen from room air and deliver oxygen at high concentration to the user via tubing, face mask, or nasal cannula. A backup system, usually an oxygen gas cylinder, accompanies a concentrator in case of power failure and is included in the rented system. “Oxygen Gas Cylinders” are green tanks that are available in various sizes and store oxygen in a gaseous state under high pressure. Portable smaller tanks can be used when away from home or as a backup system in case of power failure. Backup oxygen system is included in the rented system. When tanks are empty the vendor must replace them. “Liquid Oxygen Systems” are special thermos-like containers that store oxygen at minus 297 degrees F. They consist of a large main unit that is stationary and a separate smaller portable unit. The portable unit, used when away from home, can be refilled by the member from the large stationary unit. “Portable Oxygen” provides the user with an oxygen supply when away from home. It comes in various forms such as: an oxygen gas cylinder with attached regulator flow gauge, a portable concentrator, a small liquid oxygen system or HELiOS. It includes a regulator, tubing, mask or cannula. “Oxygen Conserving Devices (A9900)” or “Oxygen Regulators” (may also be called HELiOS), release oxygen only during inhalation. This unit replaces the traditional oxygen regulator/flowmeter, which delivers a continuous flow of oxygen. Clinical Indications General Indications Oxygen therapy is indicated when the patient has a medical condition that has been shown by evidence-based medicine to respond to the short- or long- term administration of oxygen therapy and when ALL of the following criteria are met: 2 1. The treating physician has determined that the member has a severe lung disease or hypoxia-related symptoms that has been shown by evidence-based medicine to improve with oxygen therapy; and 2. The treating physician has prescribed and indicated the type of device, delivery mechanism (cannula or mask), instructions for how it is to be used, duration of anticipated need, and oxygen flow rate; and 3. The qualifying arterial blood gas or pulse oximetry measurement was performed by a physician or by a qualified provider or supplier of laboratory services and the qualifying arterial blood gas was obtained under ONE of the following conditions: a. If the qualifying arterial blood gas study or pulse oximetry is performed during an inpatient hospital stay, no earlier than one (1) day prior to the hospital discharge date; or b. If the qualifying arterial blood gas study or pulse oximetry measurement is not performed during an inpatient hospital stay and the oxygen is being prescribed for a chronic condition, the arterial blood gas or pulse oximetry must be performed while the member is in a chronic stable state, i.e., not during acute illness or an exacerbation of their underlying disease. If pulse oximetry measurement is used, the following documentation is needed: 1. When the ear lobe or finger is used for pulse oximetry, the area used for measurement must be at or above core body temperature. The body temperature must be documented with the measurement of a surface thermometer. 4. Alternative treatment measures (e.g., pulmonary rehabilitation, medical therapy) have been tried or considered and deemed clinically ineffective; and 5. STOT or LTOT is deemed medically necessary based on the criteria below. Short Term Oxygen Therapy (STOT): The Plan considers STOT medically necessary when ALL of the following criteria are met: 1. Arterial blood gas study demonstrates PaO2 (partial pressure of oxygen) ≤59 or oxygen saturation 89% or less that may resolve with limited or short-term oxygen therapy; and 2. Documentation of hypoxia-related symptoms or findings; and 3. Diagnosis of one of the following conditions: a. Asthma; or b. Bronchitis; or c. Croup; or d. Pneumonia. Subject to medical necessity review, STOT may also be indicated for the following conditions: a. Cluster headaches when ALL the following criteria are met: i. A diagnosis of cluster headaches has been clearly established and is consistent with criteria used by the International Headache Society; and 3 ii. Member is receiving and/or is refractory to prescription preventive headache medications, or such medications are contraindicated; and iii. Member has no contraindications to high flow oxygen therapy. b. Infants with Bronchopulmonary Dysplasia (BPD) i. ii. iii. The infant’s mean pulse oximetry measures 95 percent or greater; and The infant does not have frequent episodes of oxygen desaturation; and Medical records include documentation of parent/caregiver education on equipment usage. c. Sickle cell disease with acute vaso-occlusion and hypoxia documented by arterial blood gas study Reassessment of STOT Oxygen therapy for the treatment of the above diagnoses is not considered medically necessary on an ongoing basis in the absence of special circumstances. In the absence of special circumstances, oxygen therapy requests meeting the above criteria will be authorized for up to one month. Continuation of STOT beyond the initial authorization period will require repeat arterial blood gas or pulse oximetry to demonstrate persistent hypoxemia. Long Term Oxygen Therapy (LTOT) The Plan considers medically necessary LTOT from a network durable medical equipment (DME) provider. LTOT is medically necessary when the criteria outlined in MCG Oxygen Therapy, Continuous and Noncontinuous: Home (A-0343) are met. Reassessment of LTOT The expected lifespan of Oxygen equipment is 5 years with appropriate device maintenance by the DME provider from the initiation of therapy. Reassessment of LTOT must be performed via pulse oximetry or arterial blood gas and must be performed by an independent respiratory provider at 12 months after the initiation of therapy or prior to any request for continuation of LTOT. Additional reassessments may be requested at any time at the discretion of the Plan. 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. Portable Oxygen Therapy Portable oxygen devices are reserved for those members who are physically active outside of a home environment. The treating physician must specify in the prescription the flow rate on exercise and the number of hours of therapy per day needed. Documented evidence of exertional hypoxia (e.g., six-minute walk test) is required. Oxygen therapy should be titrated to achieve an oxygen saturation of 90%. It is noteworthy that portable oxygen concentrators may require additional batteries and are not suitable for those individuals with high flow rates or those whose ventilatory patterns do not adequately trigger the device. Portable oxygen concentrators are reserved for those individuals with low flow rates and a ventilatory pattern that permits adequate oxygen saturation (i.e., >89%) and whose medical 4 documentation shows a failure to use an oxygen tank or liquid portable system with or without a conserving device. Oxygen Therapy & Travel 1. If a member travels out of his/her vendor’s service area, the member is responsible to work with his/her vendor to arrange for oxygen during travel. 2. For use on airplanes, members must work with the airline to determine what type of portable oxygen is allowed. They also need to coordinate with their oxygen DME vendor to obtain the proper equipment while traveling. Upgrades or duplicate oxygen equipment are not considered medically necessary. Experimental or Investigational / Not Medically Necessary 1. Oxygen for home use is considered experimental and investigational for the following: a. Treatment of migraine headaches b. Treatment of obstructive sleep apnea without concomitant respiratory failure as defined by the criteria above 2. Oxygen for home use is not considered medically necessary for the following: a. Angina pectoris in the absence of respiratory failure b. Dyspnea without evidence of respiratory failure c. Severe peripheral vascular disease with evidence of desaturation in one or more extremities but in the absence of systemic respiratory failure d. Terminal illness that does not affect the respiratory system