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Oxygen
Clinical Policy Bulletins Medical Clinical Policy Bulletins
Number: 0002
Policy History
Policy
I. Home oxygen therapy is only considered medically necessary if all of the following Last Review
conditions are met:

03/15/2019
A. The treating physician has determined that the member has a severe lung disease or Effective: 10/06/1995
hypoxia-related symptoms that might be expected to improve with oxygen therapy, Next
and Review: 01/09/2020
B. The member's blood gas study meets the criteria stated below, and
C. The qualifying blood gas study was performed by a physician or by a qualified Review
provider or supplier of laboratory services, and History
D. The qualifying blood gas study was obtained under the following conditions:
Definitions
1. If the qualifying blood gas study is performed during an inpatient hospital stay,
the reported test must be the one obtained closest to, but no earlier than 2 days
prior to the hospital discharge date, or
Additional
2. If the qualifying blood gas study is not performed during an inpatient hospital stay Information
and the oxygen is being prescribed for chronic conditions, the reported test must
be performed while the member is in a chronic stable state – i.e., not during a Clinical Policy
period of acute illness or an exacerbation of their underlying disease, and Bulletin

Notes
E. Alternative treatment measures have been tried or considered and deemed clinically
ineffective.
www.aetna.com/cpb/medical/data/1_99/0002.html 1/25
In this policy, the term blood gas study refers to either an oximetry test or an arterial
blood gas test.
II. Where the above-listed criteria are met, Aetna considers oxygen for home use medically
necessary durable medical equipment (DME) in the following circumstances:
A. Diagnosis of severe lung disease and qualifying lab values:**
Bronchiectasis
Chronic obstructive pulmonary disease (COPD)
Cystic fibrosis
Diffuse interstitial lung disease
Pediatric broncho-pulmonary dysplasia (BPD)
Widespread pulmonary neoplasm;
B. Diagnosis of other hypoxia-related symptoms or findings with qualifying lab values:**
Erythrocytosis (hematocrit greater than 55 %)

Pulmonary hypertension
Recurring congestive heart failure due to chronic cor-pulmonale;
C. Other diagnoses of hypoxia-related symptoms or findings with qualifying lab values:**

that usually resolve with limited or short-term oxygen therapy:
Asthma
Bronchitis
Croup
Pneumonia.
Although treatment of these diagnoses (pneumonia, asthma, croup, bronchitis) may

be considered medically necessary for short-term therapy (generally less than 1
month duration), it is not considered medically necessary on an ongoing basis absent
special circumstances. Requests for more than episodic oxygen for these diagnoses
are subject to medical review. For ongoing oxygen treatment, repeat qualifying lab
values are reviewed on a monthly basis.
D. Other diagnoses for which short-term use of oxygen has been shown to be beneficial
(unrelated to hypoxia), e.g., cluster headaches may be certified as medically
necessary on an individual case basis upon medical review:
Cluster headaches that meet the diagnostic criteria used by the International
Headache Society to form a definitive diagnosis of CH (see appendix), where the
headaches are refractory to prescription medications.
Hemoglobinopathies. Self-administration of adjunctive short-term oxygen
therapy in the outpatient setting has been shown to be beneficial and reduce
hospitalizations in individuals with hemoglobinopathies, such as hemoglobin
sickle cell disease, during vaso-occlusive crisis exacerbated by hypoxia.
Infants with BPD may have variable oxygen needs, thus, consideration on a case-
by-case basis may be required in the absence of documentation of otherwise
qualifying oxygen saturation values.
Oxygen for home use is considered experimental and investigational for indications
other than those noted above (e.g., treatment of migraine headaches, treatment
of obstructive sleep apnea, treatment of pediatric seizures, and prophylactic home
oxygen to reduce transfusion-related adverse events in pregnant women with sickle
cell disease) because its effectiveness for indications other than the ones listed above
has not been established.
**
Qualifying laboratory values:
Continuous Oxygen:
1. Resting (awake) PaO2 less than or equal to 55 mm Hg or arterial oxygen saturation

less than or equal to 88 %; or
2. Resting PaO2 of 56 to 59 mm Hg or arterial oxygen saturation of 89 % at rest

(awake), during sleep for at least 5 minutes, or during exercise (as described
below) in the presence of any of the following
Dependent edema suggesting congestive heart failure

Erythrocythemia (hematocrit greater than 56 %)
Pulmonary hypertension or cor pulmonale, determined by measurement of
pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P"
pulmonale on the electrocardiogram (P wave greater than 3 mm in standard
leads II, III, or aVF).
3. Resting PaO2 greater than 59 mm Hg or oxygen saturation greater than 89 % only

with additional documentation justifying the oxygen prescription and a summary
of more conservative therapy that has failed.
Non-continuous Oxygen: (oxygen flow rate and number of hours per day must be
specified)
1. During exercise: PaO2 less than or equal to 55 mm Hg or oxygen saturation less

than or equal to 88 % with a low level of exertion. In this case, provision of oxygen
is considered medically necessary during exercise if it is documented that the use
of oxygen improves the hypoxemia that was demonstrated during exercise when
the member was breathing room air.
2. During sleep:
a. PaO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal

to 88 % for at least 5 minutes; or
b. A decrease in PaO2 more than 10 mm Hg, or a decrease in arterial oxygen
saturation more than 5 percent from baseline saturation, for at least 5 minutes
taken during sleep associated with symptoms (e.g., impairment of cognitive
processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor
pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and
erythrocytosis) reasonably attributable to hypoxemia.
Note: All qualification studies must be done while on room air unless medically
contraindicated. Documentation of blood gas values can come from the doctor's office,
hospital or from an outpatient laboratory.
III. Oxygen therapy is considered not medically necessary for all other indications, including
the following:

A. Angina pectoris in the absence of hypoxemia. This condition is generally not the
result of a low oxygen level in the blood and there are other preferred treatments.
B. Dyspnea without cor pulmonale or evidence of hypoxemia.
C. Severe peripheral vascular disease resulting in clinically evident desaturation in one
or more extremities but in the absence of systemic hypoxemia. There is no evidence
that increased PO2 will improve the oxygenation of tissues with impaired circulation.
D. Terminal illnesses that do not affect the respiratory system.
IV. Oxygen Delivery Systems
The following delivery systems may be considered medically necessary:
Stationary: Oxygen concentrators, liquid reservoirs, or large cylinders (usually K or H

size) that are designed for stationary use.
Considered medically necessary for members who do not regularly go beyond the
limits of a stationary oxygen delivery system with a 50-ft tubing or those who use
oxygen only during sleep.
Portable: Systems that weigh 10 lbs or more and are designed to be transported but not
easily carried by the member, e.g., a steel cylinder attached to wheels (“stroller”).
Considered medically necessary for members who occasionally go beyond the limits
of a stationary oxygen delivery system with 50-ft tubing for less than 2 hours per day
for most days of the week (minimum 2 hours/week).
Preset portable oxygen units are considered not medically necessary.
Ambulatory: Systems that weigh less than 10 lbs when filled with oxygen, are designed
to be carried by the member, and will last for 4 hours at a flow equivalent to 2 L/min
continuous flow; e.g., liquid refillable units and aluminum or fiber wrapped light-weight
cylinders, with or without oxygen conserving devices.
Considered medically necessary for members who regularly go beyond the limits of a
stationary oxygen delivery system with a 50-ft tubing for 2 hours or more per day and for
most days of the week (minimum 6 hours/week).
Prescription based on the activity status of the member, the appropriate oxygen
delivery system will be delivered.
Portable Oxygen Concentrators: Portable oxygen concentrators and combination

stationary/portable oxygen systems are considered medically necessary as an
alternative to ambulatory oxygen systems for members who meet both of the following
criteria:
Member meets criteria for ambulatory oxygen systems (see above); and
Member is regularly (at least monthly) away from home for durations that exceed the
capacity of ambulatory oxygen systems.
A second oxygen tank (spare tank) is considered not medically necessary, except in
instances where the member is dependent on continuous oxygen. A single oxygen tank
may be considered medically necessary for a person who is dependent on an oxygen
concentrator.
Emergency or standby oxygen systems are considered not medically necessary.
Duplicate oxygen systems are considered convenience items and not medically
necessary, including but not limited to: provision of both a stationary and portable
oxygen concentrator; or provision of both an oxygen transfilling systems and a portable
oxygen system.
Notes: Electrical generators do not meet Aetna's definition of DME because they are not
primarily medical in nature.
Humidifiers (e.g., Vapotherm) for oxygen nasal cannula are not separately reimbursable.
Rental versus purchase: Aetna considers the rental or, if less costly, purchase of oxygen
equipment medically necessary when selection criteria are met.
The reasonable useful lifetime for oxygen equipment is 5 years. The RUL is not based on
the chronological age of the equipment. It starts on the initial date of service and runs
for 5 years from that date.
Ambulatory oxygen systems and portable oxygen concentrators are considered not

medically necessary for members who qualify for oxygen solely based on blood gas
studies obtained during sleep.
V. Reassessment
Note: Except as noted in short-term indications, reassessment of oxygen needs through

pulse oximetry or arterial blood gas is required and must be performed by an
independent respiratory provider at 12 months after the initiation of therapy for persons
who qualify for oxygen based upon an arterial PO2 at or below 55 mm Hg or an arterial
oxygen saturation at or below 88 %, or at 3 months after initiation for persons who
qualify for oxygen based upon an arterial PO2 between 56 to 59 mm Hg or an arterial
oxygen saturation of 89 % with dependent edema, P pulmonale, or erythrocythemia.
Additional reassessments may be requested at any time at the discretion of Aetna.
Reassessments must be done by an Aetna participating oxygen-qualifying company that
is in no way connected to the company supplying the oxygen therapy (as per Medicare
guidelines). 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.
VI. Aetna considers rental of airline oxygen tank medically necessary when members meet
the criteria for oxygen for home use listed above and they are not allowed to use their
own portable oxygen tank on the plane.
Note: This policy applies to all products with coverage for DME. Under plans that do not cover
DME, domiciliary oxygen may be covered on a case-by-case basis subject to medical review to
avert hospital confinement.
See CPB 0339 - Pulse Oximetry for Home Use (../300_399/0339.html) for the use of pulse
oximetry in periodically re-assessing the need for long-term oxygen in the home.
Background
This policy is supported by criteria from the Centers for Medicare & Medicaid Services (CMS).
In a Cochrane review, Bennett et al (2008) evaluated the safety and effectiveness of hyperbaric
oxygen therapy (HBOT) and normobaric oxygen therapy (NBOT) for treating and preventing
migraine and cluster headaches. These investigators searched the following in May 2008:
CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM and reference lists from relevant
articles. Relevant journals were hand-searched and researchers contacted. Randomized trials
comparing HBOT or NBOT with one another, other active therapies, placebo (sham)
interventions or no treatment in patients with migraine or cluster headache were selected for
analysis. Three reviewers independently evaluated study quality and extracted data. A total of 9
small trials involving 201 participants were included; 5 trials compared HBOT versus sham
therapy for acute migraine, 2 compared HBOT to sham therapy for cluster headache and 2
evaluated NBOT for cluster headache. Pooling of data from 3 trials suggested that HBOT was
effective in relieving migraine headaches compared to sham therapy (relative risk (RR) 5.97, 95
% confidence interval (CI): 1.46 to 24.38, p = 0.01). There was no evidence that HBOT could
prevent migraine episodes, reduce the incidence of nausea and vomiting or reduce the
requirement for rescue medication. There was a trend to better outcome in a single trial
evaluating HBOT for the termination of cluster headache (RR 11.38, 95 % CI: 0.77 to 167.85, p =
0.08), but this trial had low power. NBOT was effective in terminating cluster headache
compared to sham in a single small study (RR 7.88, 95 % CI: 1.13 to 54.66, p = 0.04), but not
superior to ergotamine administration in another small trial (RR 1.17, 95 % CI: 0.94 to 1.46, p =
0.16). Seventy-six per cent of patients responded to NBOT in these 2 trials. No serious adverse
effects of HBOT or NBOT were reported. The authors concluded that there was some evidence
that HBOT was effective for the termination of acute migraine in an unselected population, and
weak evidence that NBOT was similarly effective in cluster headache. Given the cost and poor
availability of HBOT, more research should be done on patients unresponsive to standard
therapy. NBOT is cheap, safe and easy to apply, so will probably continue to be used despite
the limited evidence in this review.
The National Institute for Health and Clinical Excellence (NICE)’s guideline on “Diagnosis and
management of headaches in young people and adults” (2012) recommended oxygen therapy
for cluster headaches; but did not mention its use for migraines.
Jurgens et al (2013) noted that while inhalation of high-flow 100 % oxygen is highly effective in
cluster headache, studies on its efficacy in migraine are sparse and controversial. These
researchers reported the case of a 22-year old patient with an 8-year history of strictly unilateral
migraine without aura but cranial autonomic symptoms. She repeatedly responded completely
to inhalation of high-flow pure oxygen within 15 mins but suffered from recurrence of attacks
within 30 mins after discontinuation. The authors concluded that in line with experimental animal
studies, this case suggested a clinically relevant efficacy of inhaled oxygen in patients with
migraine with accompanying cranial autonomic symptoms.
Furthermore, UpToDate reviews on “Acute treatment of migraine in adults” (Bajwa and Sabahat,
2013a) and “Preventive treatment of migraine in adults” (Bajwa and Sabahat, 2013b) do not
mention the use of oxygen as a management tool.
Mehta et al (2013) stated that hypoxemia is an immediate consequence of obstructive sleep

apnea (OSA). Oxygen (O2) administration has been used as an alternative treatment in patients
with OSA who do not adhere to continuous positive airway pressure (CPAP) in order to reduce
the deleterious effects of intermittent hypoxemia during sleep. These researchers investigated
the effects of O2 therapy on patients with OSA. They conducted a systematic search of the
databases Medline, Embase, Cochrane Central Register of Controlled Trials (1st Quarter 2011),
Cochrane Database of Systematic Reviews (from 1950 to February 2011). The search strategy
yielded 4,793 citations. Irrelevant papers were excluded by title and abstract review, leaving 105
manuscripts. These investigators reviewed all prospective studies that included: (i) a target
population with OSA, (ii) O2 therapy and/or CPAP as a study intervention, (iii) the effects of
O2 on the apnea-hypopnea index (AHI), nocturnal hypoxemia, or apnea duration. These
researchers identified 14 studies including a total of 359 patients; 9 studies were of single cohort
design, while 5 studies were randomized control trials (RCTs) with 3 groups (CPAP, O2, and
placebo/sham CPAP). When CPAP was compared to O2 therapy, all but 1 showed a significant
improvement in AHI. Ten studies demonstrated that O2 therapy improved oxygen saturation
versus placebo. However, the average duration of apnea and hypopnea episodes were longer in
patients receiving O2 therapy than those receiving placebo. The authors concluded that the
findings of this review showed that O2 therapy significantly improves oxygen saturation in
patients with OSA. However, it may also increase the duration of apnea-hypopnea events.
Gottlieb and colleagues (2014) stated that OSA is associated with hypertension, inflammation,
and increased cardiovascular risk. Continuous positive airway pressure reduces blood pressure
(BP), but adherence is often suboptimal, and the benefit beyond management of conventional
risk factors is uncertain. Since intermittent hypoxemia may underlie cardiovascular sequelae of
sleep apnea, these researchers evaluated the effects of nocturnal supplemental O2 and CPAP
on markers of cardiovascular risk. They conducted a RCT in which patients with cardiovascular
disease or multiple cardiovascular risk factors were recruited from cardiology practices. Patients
were screened for OSA with the use of the Berlin questionnaire, and home sleep testing was
used to establish the diagnosis. Participants with an AHI of 15 to 50 events per hour were
randomly assigned to receive education on sleep hygiene and healthy lifestyle alone (the control
group) or, in addition to education, either CPAP or nocturnal supplemental O2. Cardiovascular
risk was assessed at baseline and after 12 weeks of the study treatment. The primary outcome
was 24-hour mean arterial BP. Of 318 patients who underwent randomization, 281 (88 %) could
be evaluated for ambulatory BP at both baseline and follow-up. On average, the 24-hour mean
arterial BP at 12 weeks was lower in the group receiving CPAP than in the control group (-2.4
mm Hg; 95 % CI: -4.7 to -0.1; p = 0.04) or the group receiving supplemental O2 (-2.8 mm Hg; 95
% CI: -5.1 to -0.5; p = 0.02). There was no significant difference in the 24-hour mean arterial BP
between the control group and the group receiving oxygen. A sensitivity analysis performed with
the use of multiple imputation approaches to assess the effect of missing data did not change
the results of the primary analysis. The authors concluded that in patients with cardiovascular
disease or multiple cardiovascular risk factors, the treatment of OSA with CPAP, but not
nocturnal supplemental O2, resulted in a significant reduction in BP.
Furthermore, UpToDate reviews on “Management of obstructive sleep apnea in adults” (Kryger

and Malhotra, 2014) and “Overview of obstructive sleep apnea in adults” (Strohl, 2014) do not
mention oxygen as a therapeutic option.
Acute Myocardial Infarction
Fu and colleagues (2017) stated that potential benefits or risks of oxygen inhalation for patients
with acute myocardial infarction (MI) are not fully understood. In a systematic review and meta-
analysis, these researchers evaluated the safety and effectiveness of oxygen therapy for
patients with acute MI. They searched RCTs systematically in PubMed, Embase, Web of
Science and Cochrane Library up to June 2016; RCTs that estimated the safety and
effectiveness of oxygen therapy for patients with acute MI were identified by 2 independent
reviewers. The primary outcomes were short-term mortality and recurrent rate of MI, and the
secondary outcomes were arrhythmia incidence and pain incidence; RRs and 95 % CIs were
used to measure the pooled data. A total of 5 RCTs were in accordance with inclusion criteria
and were included in this meta-analysis. Compared with no oxygen group, the oxygen group did
not significantly reduce short-term death (RR: 1.08, 95 % CI: 0.31 to 3.74), and there was
moderate heterogeneity (I2 = 50.8 %, p < 0.107) among studies. These investigators found a
significant increase in the rate of recurrent MI (RR: 6.73, 95 % CI: 1.80 to 25.17, I2 = 0.0 %, p =
0.598) in the oxygen group. The oxygen group did not have a significant reduction in arrhythmia
(RR: 1.12, 95 % CI: 0.91 to 1.36; I2 = 46.2 %, p < 0.156) or pain (RR: 0.97, 95 % CI: 0.91 to
1.04; I2 = 7.2 %, p = 0.340). The authors concluded that oxygen inhalation did not benefit
patients with acute MI with normal oxygen saturation; and it may increase the rate of recurrent
MI. They stated that high quality trials with larger sample sizes are needed.
Hofmann and associates (2017) noted that the clinical effect of routine oxygen therapy in
patients with suspected acute MI who do not have hypoxemia at baseline is uncertain. In this
registry-based randomized clinical trial, these researchers used nationwide Swedish registries
for patient enrollment and data collection. Patients with suspected MI and an oxygen saturation
of 90 % or higher were randomly assigned to receive either supplemental oxygen (6 L/min for 6
to 12 hours, delivered through an open face mask) or ambient air. A total of 6,629 patients were
enrolled. The median duration of oxygen therapy was 11.6 hours, and the median oxygen
saturation at the end of the treatment period was 99 % among patients assigned to oxygen and
97 % among patients assigned to ambient air. Hypoxemia developed in 62 patients (1.9 %) in
the oxygen group, as compared with 254 patients (7.7 %) in the ambient-air group. The median
of the highest troponin level during hospitalization was 946.5 ng/Lin the oxygen group and 983.0
ng/L in the ambient-air group. The primary end-point of death from any cause within 1 year after
randomization occurred in 5.0 % of patients (166 of 3,311) assigned to oxygen and in 5.1 % of
patients (168 of 3,318) assigned to ambient air (hazard ratio [HR], 0.97; 95 % CI: 0.79 to 1.21; p
= 0.80). Re-hospitalization with MI within 1 year occurred in 126 patients (3.8 %) assigned to
oxygen and in 111 patients (3.3 %) assigned to ambient air (HR, 1.13; 95 % CI: 0.88 to 1.46; p =
0.33). The results were consistent across all pre-defined subgroups. The authors concluded
that routine use of supplemental oxygen in patients with suspected MI who did not have
hypoxemia was not found to reduce 1-year all-cause mortality.
Acute Respiratory Failure in Immunocompromised Individuals
Huang and colleagues (2017) evaluated the effect of high-flow nasal cannula oxygen therapy
(HFNC) compared with other oxygen technique for the treatment of acute respiratory failure in
immunocompromised individuals. These investigators searched Cochrane library, Embase,
PubMed databases before August 15, 2017 for eligible articles. A meta-analysis was performed
for measuring short-term mortality (defined as intensive care unit [ICU], hospital or 28-days
mortality) and intubation rate as the primary outcomes, and length of stay (LOS) in ICU as the
secondary outcome. They included 7 studies involving 667 patients. Use of HFNC was
significantly associated with a reduction in short-term mortality (RR 0.66; 95 % CI: 0.52 to 0.84, p
= 0.0007) and intubation rate (RR 0.76, 95 % CI: 0.64 to 0.90; p = 0.002). In addition, HFNC did
not significantly increase LOS in ICU (MD 0.15 days; 95 % CI: -2.08 to 2.39; p = 0.89). The
authors concluded that the findings of the current meta-analysis suggested that the use of HFNC
significantly improved outcomes of acute respiratory failure in immunocompromised patients.
However, due to the quality of the included studies, further adequately powered RCTs are
needed to confirm these findings.
In a Cochrane review, Corley and associates (2017) the safety and effectiveness of HFNC
compared with comparator interventions in terms of treatment failure, mortality, adverse events
(AEs), duration of respiratory support, hospital and ICU-LOS, respiratory effects, patient-reported
outcomes, and costs of treatment. These investigators searched the Cochrane Central Register
of Controlled Trials (CENTRAL; 2016, Issue 3), Medline, the Cumulative Index to Nursing and
Allied Health Literature (CINAHL), Embase, Web of Science, proceedings from four conferences,
and clinical trials registries; and they hand-searched reference lists of relevant studies. They
conducted searches from January 2000 to March 2016 and re-ran the searches in December
2016. They added 4 new studies of potential interest to a list of “Studies awaiting classification”
and incorporated them into formal review findings during the review update. These researchers
included randomized controlled studies with a parallel or cross-over design comparing HFNC
use in adult ICU patients versus other forms of non-invasive respiratory support (low-flow oxygen
via nasal cannulae or mask, CPAP, and bi-level positive airway pressure (BiPAP)). Two review
authors independently assessed studies for inclusion, extracted data, and assessed risk of bias.
They included 11 studies with 1,972 participants. Participants in 6 studies had respiratory failure,
and in 5 studies required oxygen therapy after extubation; 10 studies compared HFNC versus
low-flow oxygen devices; 1 of these also compared HFNC versus CPAP, and another compared
HFNC versus BiPAP alone. Most studies reported randomization and allocation concealment
inadequately and provided inconsistent details of outcome assessor blinding. These researchers
did not combine data for CPAP and BiPAP comparisons with data for low-flow oxygen devices;
study data were insufficient for separate analysis of CPAP and BiPAP for most outcomes. For
the primary outcomes of treatment failure (1,066 participants; 6 studies) and mortality (755
participants; 3 studies), investigators found no differences between HFNC and low-flow oxygen
therapies (RR, Mantel-Haenszel (MH), random-effects 0.79, 95 % CI: 0.49 to 1.27; and RR, MH,
random-effects 0.63, 95 % CI: 0.38 to 1.06, respectively). These investigators used the GRADE
approach to downgrade the certainty of this evidence to low because of study risks of bias and
different participant indications. Reported AEs included nosocomial pneumonia, oxygen
desaturation, visits to general practitioner for respiratory complications, pneumothorax, acute
pseudo-obstruction, cardiac dysrhythmia, septic shock, and cardiorespiratory arrest. However,
single studies reported AEs, and the authors could not combine these findings; 1 study reported
fewer episodes of oxygen desaturation with HFNC but no differences in all other reported AEs.
These researchers down-graded the certainty of evidence for AEs to low because of limited
data. Researchers noted no differences in ICU-LOS(mean difference (MD), inverse variance
(IV), random-effects 0.15, 95 % CI: -0.03 to 0.34; 4 studies; 770 participants), and they down-
graded quality to low because of study risks of bias and different participant indications. They
found no differences in oxygenation variables: partial pressure of arterial oxygen (PaO2)/fraction
of inspired oxygen (FiO2) (MD, IV, random-effects 7.31, 95 % CI: -23.69 to 41.31; 4 studies; 510
participants); PaO2 (MD, IV, random-effects 2.79, 95 % CI: -5.47 to 11.05; 3 studies; 355
participants); and oxygen saturation (SpO2) up to 24 hours (MD, IV, random-effects 0.72, 95 %
CI: -0.73 to 2.17; 4 studies; 512 participants). Data from 2 studies showed that oxygen
saturation measured after 24 hours was improved among those treated with HFNC (MD, IV,
random-effects 1.28, 95 % CI: 0.02 to 2.55; 445 participants), but this difference was small and
was not clinically significant. Along with concern about risks of bias and differences in participant
indications, review authors noted a high level of unexplained statistical heterogeneity in
oxygenation effect estimates, and they down-graded the quality of evidence to very low. Meta-
analysis of 3 comparable studies showed no differences in carbon dioxide clearance among
those treated with HFNC (MD, IV, random-effects -0.75, 95 % CI: -2.04 to 0.55; 3 studies; 590
participants); 2 studies reported no differences in atelectasis; the authors did not combine these
findings. Data from 6 studies (867 participants) comparing HFNC versus low-flow oxygen
showed no differences in respiratory rates up to 24 hours according to type of oxygen delivery
device (MD, IV, random-effects -1.51, 95 % CI: -3.36 to 0.35), and no difference after 24 hours
(MD, IV, random-effects -2.71, 95 % CI: -7.12 to 1.70; 2 studies; 445 participants). Improvement
in respiratory rates when HFNC was compared with CPAP or BiPAP was not clinically important
(MD, IV, random-effects -0.89, 95 % CI: -1.74 to -0.05; 2 studies; 834 participants). Results
showed no differences in patient-reported measures of comfort according to oxygen delivery
devices in the short-term (MD, IV, random-effects 0.14, 95 % CI: -0.65 to 0.93; 3 studies; 462
participants) and in the long-term (MD, IV, random-effects -0.36, 95 % CI: -3.70 to 2.98; 2
studies; 445 participants); these researchers down-graded the certainty of this evidence to low; 6
studies measured dyspnea on incomparable scales, yielding inconsistent study data. No study
in this review provided data on positive end-expiratory pressure (PEEP) measured at the
pharyngeal level, work of breathing, or cost comparisons of treatment. The authors were unable
to demonstrate whether HFNC was a more safe or effective oxygen delivery device compared
with other oxygenation devices in adult ICU patients. Meta-analysis could be performed for few
studies for each outcome, and data for comparisons with CPAP or BiPAP were very limited. In
addition, they identified some risks of bias among included studies, differences in patient groups,
and high levels of statistical heterogeneity for some outcomes, leading to uncertainty regarding
the results of this analysis. Thus, they stated that evidence is insufficient to show whether HFNC
provided safe and effective respiratory support for adult ICU patients.
Acute Stroke
In a single-blind, randomized clinical trial, Roffe and colleagues (2017) examined if routine
prophylactic low-dose oxygen therapy was more effective than control oxygen administration in
reducing death and disability at 90 days, and if so, whether oxygen given at night only, when
hypoxia is most frequent, and oxygen administration is least likely to interfere with rehabilitation,
was more effective than continuous supplementation. A total of 8,003 adults with acute stroke
were enrolled from 136 participating centers in the United Kingdom within 24 hours of hospital
admission if they had no clear indications for or contraindications to oxygen treatment (1st
patient enrolled April 24, 2008; last follow-up January 27, 2015). Participants were randomized
1:1:1 to continuous oxygen for 72 hours (n = 2,668), nocturnal oxygen (21:00 to 07:00 hours) for
3 nights (n = 2,667), or control (oxygen only if clinically indicated; n = 2,668). Oxygen was given
via nasal tubes at 3 L/min if baseline oxygen saturation was 93 % or less and at 2 L/min if
oxygen saturation was greater than 93 %. The primary outcome was reported using the
modified Rankin Scale (mRS) score (disability range, 0 [no symptoms] to 6 [death]; minimum
clinically important difference, 1 point), assessed at 90 days by postal questionnaire (participant
aware, assessor blinded). The mRS score was analyzed by ordinal logistic regression, which
yielded a common odds ratio (OR) for a change from 1 disability level to the next better (lower)
level; or greater than 1.00 indicates improvement. A total of 8,003 patients (4,398 (55 %) men;
mean [SD] age of 72 [13] years; median National Institutes of Health Stroke Scale (NIHSS) score
of 5; mean baseline oxygen saturation, 96.6 %) were enrolled. The primary outcome was
available for 7,677 (96 %) participants. The unadjusted OR for a better outcome (calculated via
ordinal logistic regression) was 0.97 (95 % CI: 0.89 to 1.05; p = 0.47) for oxygen versus control,
and the OR was 1.03 (95 % CI: 0.93 to 1.13; p = 0.61) for continuous versus nocturnal oxygen.
No subgroup could be identified that benefited from oxygen. At least 1 serious adverse event
(AE) occurred in 348 (13.0 %) participants in the continuous oxygen group, 294 (11.0 %) in the
nocturnal group, and 322 (12.1 %) in the control group. No significant harms were identified.
The authors concluded that among non-hypoxic patients with acute stroke, the prophylactic use
of low-dose oxygen supplementation did not reduce death or disability at 3 months. They stated
that these findings did not support low-dose oxygen in this setting.
Reduction of Transfusion-Related Adverse Events in Pregnant Women with Sickle Cell

Disease
Ribeil and colleagues (2018) noted that sickle cell disease (SCD) in pregnancy can be
associated with adverse maternal and perinatal outcomes. Furthermore, complications of SCD
can be aggravated by pregnancy. Optimal prenatal care aims to decrease the occurrence of
maternal and fetal complications. In a retrospective, French, 2-center study, these investigators
compared 2 care strategies for pregnant women with SCD over 2 time-periods. In the 1st study
period (2005 to 2010), women were systematically offered prophylactic transfusions. In the 2nd
study period (2011 to 2014), a targeted transfusion strategy was applied whenever possible, and
home-based prophylactic nocturnal oxygen therapy was offered to all the pregnant women. The
2 periods did not differ significantly in terms of the incidence of vaso-occlusive events. Maternal
mortality, perinatal mortality, and obstetric complication rates were also similar in the 2 periods,
as was the incidence of post-transfusion complications (6.1 % in 2005 to 2010 and 1.3 % in 2011
to 2014, p = 0.15), although no de-novo allo-immunizations or delayed hemolysis transfusion
reactions were observed in the 2nd period. The authors concluded that the findings of this
preliminary, retrospective study indicated that targeted transfusion plus home-based prophylactic
nocturnal oxygen therapy was safe and may decrease transfusion requirements and transfusion-
associated complications. They stated that the use of prophylactic home oxygen therapy in SCD
appeared promising as their patients currently request this new therapeutic option (despite its
constraints); the preliminary results in previous studies have been positive; and a pilot study of
morbidity prevention in SCD by overnight supplementary oxygen has recently been initiated.
These researchers stated that their forthcoming prospective multi-center RCT should enable
them to establish a severity score and therefore adapt the therapeutic strategy according to a
patient's risk factors.
The authors stated that no definitive conclusion could be drawn from this retrospective study of 2
concomitant changes in their treatment strategy (i.e., targeted transfusion and prophylactic
oxygen therapy). The methodological drawback of retrospective studies was highlighted in a
recent meta‐analysis by Malinowski et al. Considering this limitation, these researchers have set
up a prospective, multi-center RCT of prophylactic oxygen therapy during SCD pregnancies. In
fact, these investigators hypothesize that prophylactic oxygen therapy relieves the symptoms of
SCD (particularly during pregnancy). Accordingly, they intend to examine if an independent
effect on treatment outcomes exists in this high‐risk medical setting. The study will investigate
whether prophylactic oxygen therapy will decrease the transfusion requirement and the
incidence of severe post‐transfusion complications without increasing the incidence of vaso‐
occlusive crises or obstetric complications. If this end-point is met, prophylactic oxygen therapy
may be of major value, especially in regions with sub‐optimal transfusion safety. All the pregnant
women with SCD in this ongoing RCT will undergo oximetry measurements for 2 consecutive
nights so that these researchers can establish whether the results are significant in a hypoxic
subgroup only.
Treatment of Pediatric Seizures
There are a lack of published clinical studies of the effectiveness of home oxygen as a treatment
for epilepsy in children. UpToDate reviews on “Seizures and epilepsy in children: Initial treatment
and monitoring” (Wilfong, 2018a) and “Seizures and epilepsy in children: Refractory seizures and
prognosis” (Wilfong, 2018b) do not mention oxygen as a therapeutic option.
Appendix
Documentation Requirements
Documentation, in the form of a prescription written by the physician, must include an estimate of
the frequency, duration of use, duration of need, type of system to be used and oxygen flow rate.
A physician's statement of recent hospital test results is also acceptable as well as arterial
oxygen saturation obtained by pulse oximetry:
International Headache Society Diagnostic Criteria for Cluster Headache
Aetna uses diagnostic criteria used by the International Headache Society to form a definitive
diagnosis of CH. Therefore, the home use of oxygen to treat CH is considered medically
necessary by Aetna only when furnished to members who have had at least five severe to very
severe unilateral headache attacks lasting 15-180 minutes when untreated. (Intensity of pain:
Degree of pain usually expressed in terms of its functional consequence and scored on a verbal
5-point scale: 0=no pain; 1=mild pain, does not interfere with usual activities; 2=moderate pain,
inhibits but does not wholly prevent usual activities; 3=severe pain, prevents all activities; 4=very
severe pain. It may also be expressed on a visual analogue scale.)
The headaches must be accompanied by at least one of the following findings:
1. Ipsilateral conjunctival injection and/or lacrimation; or

2. Ipsilateral nasal congestion and/or rhinorrhea; or
3. Ipsilateral eyelid edema; or
4. Ipsilateral forehead and facial sweating; or
5. Ipsilateral miosis and/or ptosis; or
6. A sense of restlessness or agitation
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring
a 7th character are represented by "+":
Code Code Description
Other CPT codes related to the CPB:
82803 - 82810 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated
O2 saturation); with O2 saturation, by direct measurement, except pulse oximetry; or
gases, blood, O2 saturation only, by direct measurement, except pulse oximetry
94010 - 94777 Pulmonary medicine
99503 Home visit for respiratory therapy care (e.g., bronchodilator, oxygen therapy,
respiratory assessment, apnea evaluation)
99504 Home visit for mechanical ventilation care
HCPCS codes covered if selection criteria are met:
E0424 Stationary compressed gaseous oxygen system, rental; includes container,
contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter,
humidifier, nebulizer, cannula or mask, and tubing
E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter,
humidifier, cannula or mask, and tubing
E0431 Portable gaseous oxygen system, rental; includes portable container, regulator,
flowmeter, humidifier, cannula or mask, and tubing
E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid
oxygen containers, includes portable containers,regulator, flowmeter, humidifier,
cannula or mask and tubing, with or without supply reservoir and content gauge
E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir,
humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0435 Portable liquid oxygen system purchase; includes portable container, supply
reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill
adaptor
E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator,
flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents
indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0441 Oxygen contents, gaseous (for use with owned gaseous stationary systems or when
both a stationary and portable gaseous system are owned), 1 month's supply = 1
unit
E0442 Oxygen contents, liquid (for use with owned liquid stationary systems or when both a
stationary and portable liquid system are owned), 1 month's supply = 1 unit
E0443 Portable oxygen contents, gaseous (for use only with portable gaseous systems
when no stationary gas or liquid system is used), 1 month's supply = 1 unit
E0444 Portable oxygen contents, liquid (for use only with portable liquid systems when no
stationary gas or liquid system is used), 1 month's supply = 1 unit
E0447 Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at
rest or nighttime exceeds 4 liters per minute (lpm)
E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or
greater oxygen concentration at the prescribed flow rate
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater
oxygen concentration at the prescribed flow rate, each
E1392 Portable oxygen concentrator, rental
E1405 Oxygen and water vapor enriching system with heated delivery
E1406 Oxygen and water vapor enriching system without heated delivery
K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable
oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier,
cannula or mask, and tubing
S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot
S8121 Oxygen contents, liquid, 1 unit equals 1 pound
Other HCPCS codes related to the CPB:
A4611 Battery, heavy-duty; replacement for patient-owned ventilator
A4612 Battery cables; replacement for patient-owned ventilator
A4613 Battery charger; replacement for patient-owned ventilator
A4615 Cannula, nasal
A4616 Tubing (oxygen), per foot
A4617 Mouthpiece
A4618 Breathing circuits
A4619 Face tent
A4620 Variable concentration mask
A7046 Water chamber for humidifier, used with positive airway pressure device,
replacement, each
E0445 Oximeter device for measuring blood oxygen levels non-invasively
E0455 Oxygen tent, excluding croup or pediatric tents
E0457 Chest shell (cuirass)
E0459 Chest wrap
E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
E0467 Home ventilator, multi-function respiratory device, also performs any or all of the
additional functions of oxygen concentration, drug nebulization, aspiration, and
cough stimulation, includes all accessories, components and supplies for all
functions
E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature,
used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device
with continuous positive airway pressure device)
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature,
used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device
with continuous positive airway pressure device)
E0472 Respiratory assist device, bi-level pressure capability, with back-up rate feature,
used with invasive interface, e.g., tracheostomy tube (intermittent assist device with
continuous positive airway pressure device)
E0500 IPPB machine, all types, with built-in nebulization; manual or automatic valves;
internal or external power source
E0550 Humidifier, durable for extensive supplemental humidification during IPPB
treatments or oxygen delivery
E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or
flowmeter
E0560 Humidifier, durable for supplemental humidification during IPPB treatment or oxygen
delivery
E0561 Humidifier, non-heated, used with positive airway pressure device
E0562 Humidifier, heated, used with positive airway pressure device
E1352 Oxygen accessory, flow regulator capable of positive inspiratory pressure
E1353 Regulator
E1354 Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any
type, replacement only, each
E1355 Stand/rack
E1356 Oxygen accessory, battery pack / cartridge for portable concentrator, any type,
replacement only, each
E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement
only, each
E1358 Oxygen accessory, DC power adapter for portable concentrator, any type,
replacement only, each
ICD-10 codes covered if selection criteria are met (not all-inclusive):
A22.1 Pulmonary anthrax
A37.01, A37.11, Pneumonia in whooping cough
A37.81, A37.91
A48.1 Legionnaires' disease
B25.0 Cytomegaloviral pneumonitis
B44.0 Invasive pulmonary aspergillosis
B77.81 Ascariasis pneumonia
C34.00 - C34.92 Malignant neoplasm of bronchus and lung
C78.00 - C78.02 Secondary malignant neoplasm of lung
C94.00 - C94.02 Acute erythroid leukemia
D02.20 - D02.22 Carcinoma in situ of bronchus and lung
D14.30 - D14.32 Benign neoplasm of bronchus and lung
D45 Polycythemia vera
D56.0 - D56.9 Thalassemia
D57.00 - D57.219 Sickle-cell disorders
D57.40 - D57.819
D58.1 - D58.2 Hereditary elliptocytosis and other hemoglobinopathies
D75.0 - D75.1 Familial erythrocytosis and secondary polycythemia
E84.0 - E84.9 Cystic fibrosis
G44.001 - G44.029 Cluster headaches
I26.01 - I26.09 Pulmonary embolism with acute cor pulmonale
I27.0 - I27.9 Other pulmonary heart diseases
I46.2 - I49.9 Cardiac arrest, paroxysmal tachycardia, atrial fibrillation and flutter and other cardiac
arrhythmias
I50.20 - I50.9 Congestive heart failure
J05.0 Acute obstructive laryngitis [croup]
J12.0 - J18.1 Pneumonia
J18.8 - J18.9
J40 - J42 Bronchitis and other chronic obstructive pulmonary disease
J44.0 - J44.9
J45.20 - J45.998 Asthma
J47.0 - J47.9 Bronchiectasis
J84.10 Pulmonary fibrosis, unspecified
P27.0 - P27.9 Chronic respiratory diseases originating in the perinatal period
P29.30 - P29.38 Persistent fetal circulation
Q33.4 Congenital bronchiectasis
R00.1 Bradycardia, unspecified
R60.0 - R60.9 Edema, not elsewhere classified
Z99.81 Dependence on supplemental oxygen
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
G40.B01 - G40.B09 Juvenile myoclonic epilepsy, not intractable [pediatric seizures]
G40.B11 - G40.B19 Juvenile myoclonic epilepsy, intractable [pediatric seizures]
G43.001 - G43.919 Migraine
G47.33 Obstructive sleep apnea (adult) (pediatric)
I20.0 - I20.9 Angina pectoris [in the absence of hypoxemia]
I73.81 - I73.9 Other peripheral vascular diseases [resulting in clinically evident desaturation in one
or more extremities but in the absence of systemic hypoxemia]
R06.00 - R06.09 Dyspnea [without cor pulmonale or evidence of hypoxemia]
The above policy is based on the following references:

1. Petty TL, O'Donohue WJ Jr. Further recommendations for prescribing, reimbursement,
technology development, and research in long-term oxygen therapy. Summary of the
Fourth Oxygen Consensus Conference, Washington, DC, October 15-16, 1993. Am Respir
Critl Care Med. 1994;150(3):875-877.
2. U.S. Department of Health and Human Services, Center for Medicare & Medicaid
Services (CMS). Evidence of medical necessity for home oxygen therapy. Medicare
Carriers Manual §3312. Baltimore, MD: CMS; 2002.
3. Sanchez Agudo L, Cornudella R, Estopa Miro R, et al. Guidelines for indications and use
of domiciliary continuous oxygen (DCO) therapy. SEPAR guidelines. Arch
Bronconeumol. 1998;34(2):87-94.
4. O'Donohue WJ Jr. Home oxygen therapy. Clin Chest Med. 1997;18(3):535-545.
5. O'Donohue WJ Jr. Home oxygen therapy. Med Clin North Am. 1996;80(3):611-622.
6. Wilkinson J, Rees J. Domiciliary oxygen. Br J Clin Pract. 1996;50(3):151-153.
7. Weitzenblum E. Observance of long-term oxygen therapy at home. Chest.
1996;109(5):1135-1136.
8. Tarpy SP, Celli BR. Long-term oxygen therapy. N Engl J Med. 1995;333(11):710-714.
9. Tiep BL. Long-term home oxygen therapy. Clin Chest Med. 1990;11(3):505-521.
10. Herrick TW, Yeager H Jr. Home oxygen therapy. Am Fam Physician. 1989;39(2):157-162.
11. Petty TL. Home oxygen therapy. Mayo Clin Proc. 1987;62(9):841-847.
12. Okpala I. The management of crisis in sickle cell disease. Eur J Haematol. 1998;60(1):1-
6.
13. Zipursky A, Robieux IC, Brown FJ, et al. Oxygen therapy in sickle cell disease. Am J
Pediatr Hematol Oncl. 1992;14(3):222-228.
14. U.S. Department of Health and Human Services, Center for Medicare and Medicaid
Services (CMS). Home use of oxygen. Medicare Coverage Issues Manual §60-64.
Baltimore, MD: CMS, 2002.
15. Cranston JM, Crockett AJ, Moss JR, Alpers JH. Domiciliary oxygen for chronic obstructive
pulmonary disease. Cochrane Database Syst Rev. 2005;(4):1744.
16. Ram FS, Wedzicha JA. Ambulatory oxygen for chronic obstructive pulmonary disease.
Cochrane Database Syst Rev. 2002:(2):CD000238.
17. Dunne PJ. The demographics and economics of long-term oxygen therapy. Respir Care.
2000;45(2):223-228; discussion 228-230.
18. O'Donohue WJ Jr, Bowman TJ. Hypoxemia during sleep in patients with chronic
obstructive pulmonary disease: Significance, detection, and effects of therapy. Respir
Care. 2000;45(2):188-191; discussion 192-193.
19. Kotecha S, Allen J. Oxygen therapy for infants with chronic lung disease. Arch Dis Child
Fetal Neonatal Ed. 2002;87(1):F11-F14.
20. Banken R. Home oxygen therapy for the treatment of cluster headache. AETMIS 02-01
NE. Montreal, QC: Agence d'Evaluation des Technologies et des Modes d'Intervention
en Sante (AETMIS); 2002.
21. Gracey K, Talbot D, Lankford R, Dodge P. The changing face of bronchopulmonary
dysplasia: Part 2. Discharging an infant home on oxygen. Adv Neonatal Care.
2003;3(2):88-98.
22. Agence D'Evaluation des Technologies et des Modes D'Intervention en Sante (AETMIS).
Portable oxygen therapy for COPD. Hospital Technology at Home. AETMIS 04-03.
Montreal, QC; AETMIS; July 2004.
23. Lau J, Chew P, Wang C, White A. Long term oxygen therapy for severe COPD. Prepared
for AHRQ by Tufts-New England Medical Center Evidence-Based Practice Center
under Contract No. 290-02-0022. Rockville, MD: Agency for Healthcare Research and
Quality (AHRQ); June 11, 2004.
24. Lacasse Y, Lecours R, Pelletier C, Begin R, Maltais F. Randomised trial of ambulatory
oxygen in oxygen-dependent COPD. Eur Respir J. 2005;25(6):1032-1038.
25. Bradley JM, O'Neill B. Short term ambulatory oxygen for chronic obstructive pulmonary
disease. Cochrane Database Syst Rev. 2005;(2):CD004356.
26. McDonald CF, Crockett AJ, Young IH. Adult domiciliary oxygen therapy. Position
statement of the Thoracic Society of Australia and New Zealand. Med J Aust.
2005;182(12):621-626.
27. Centers for Medicare and Medicaid Services (CMS). Decision memo for home use of
oxygen (CAG-00296N). Medicare Coverage Database. Rockville, MD: CMS; March 20,
2006.
28. Mallory GB, Fullmer JJ, Vaughan DJ. Oxygen therapy for cystic fibrosis. Cochrane
Database Syst Rev. 2005;(4):CD003884.
29. Ait-Khaled N, Enarson DA. Managing acute attacks of asthma. Int J Tuberc Lung Dis.
2006;10(5):484-489.
30. Greenough A. Bronchopulmonary dysplasia--long term follow up. Paediatr Respir Rev.
2006;7 Suppl 1:S189-S191.
31. Austin M, Wood-Baker R. Oxygen therapy in the pre-hospital setting for acute
exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev.
2006;(3):CD005534.
32. Nonoyama ML, Brooks D, Lacasse Y, et al. Oxygen therapy during exercise training in
chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2007;
(2):CD005372.
33. Say L, Gülmezoglu AM, Hofmeyr GJ. Maternal oxygen administration for suspected
impaired fetal growth. Cochrane Database Syst Rev. 2005;(1):CD000137.
34. Bradley JM, Lasserson T, Elborn S, et al. A systematic review of randomized controlled
trials examining the short-term benefit of ambulatory oxygen in COPD. Chest.
2007;131(1):278-285.
35. American Association of Respiratory Care (AARC). AARC clinical practice guideline.
Oxygen therapy in the home or alternate site health care facility--2007 revision &
update. Respir Care. 2007;52(8):1063-1068.
36. Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane
Database Syst Rev. 2008;(3):CD004769.
37. Thoracic Society of Australia and New Zealand, Fitzgerald DA, Massie RJ, Nixon GM, et
al. Infants with chronic neonatal lung disease: Recommendations for the use of home
oxygen therapy. Med J Aust. 2008;189(10):578-582.
38. Balfour-Lynn IM. Domiciliary oxygen for children. Pediatr Clin North Am.
2009;56(1):275-296, xiii.
39. Van Meerhaeghe A, Annemans L, Haentjens P, et al. Home oxygen therapy. KCE
Reports 156C. Brussels, Belgium: Belgian Health Care Knowledge Centre (KCE); 2011.
40. NHIC, Corp. Local coverage article for oxygen and oxygen equipment. Policy Article
A33768. Durable Medical Equipment Medicare Administrative Contactor (DME MAC)
Jurisdiction A. Hingham, MA: NHIC; revised October 2012.
41. NHIC, Corp. Local coverage determination for oxygen and oxygen equipment (L11468).
Durable Medical Equipment Medicare Administrative Contractor (DME MAC)
Jurisdiction A. Hingham, MA: NHIC; revised January 1, 2013.
42. Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy
for migraine and cluster headache. Cochrane Database Syst Rev. 2008;(3):CD005219.
43. National Clinical Guideline Centre. Headaches: Diagnosis and management of
headaches in young people and adults. London, UK: National Institute for Health and
Clinical Excellence (NICE); September 2012.
44. Jurgens TP, Schulte LH, May A. Oxygen treatment is effective in migraine with
autonomic symptoms. Cephalalgia. 2013;33(1):65-67.
45. Bajwa ZH, Sabahat A. Acute treatment of migraine in adults. UpToDate [online serial].
Waltham, MA: UpToDate; reviewed November 2013a.
46. Bajwa ZH, Sabahat A. Preventive treatment of migraine in adults. UpToDate [online
serial]. Waltham, MA: UpToDate; reviewed November 2013b.
47. Mehta V, Vasu TS, Phillips B, Chung F. Obstructive sleep apnea and oxygen therapy: A
systematic review of the literature and meta-analysis. J Clin Sleep Med. 2013;9(3):271-
279.
48. Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea.
N Engl J Med. 2014;370(24):2276-2285.
49. Kryger MH, Malhotra A. Management of obstructive sleep apnea in adults. UpToDate
[online serial]. Waltham, MA: UpToDate; reviewed September 2014.
50. Strohl KP. Overview of obstructive sleep apnea in adults. UpToDate [online
serial]. Waltham, MA: UpToDate; reviewed September 2014.
51. Hardinge M, Annandale J, Bourne S, et al; British Thoracic Society Home Oxygen
Guideline Development Group; British Thoracic Society Standards of Care Committee.
British Thoracic Society guidelines for home oxygen use in adults. Thorax. 2015;70
Suppl 1:i1-i43.
52. Clark AL, Johnson M, Fairhurst C, et al. Does home oxygen therapy (HOT) in addition to
standard care reduce disease severity and improve symptoms in people with chronic
heart failure? A randomised trial of home oxygen therapy for patients with chronic
heart failure. Health Technol Assess. 2015;19(75):1-120.
53. Hardinge M, Suntharalingam J, Wilkinson T; British Thoracic Society. Guideline update:
The British Thoracic Society Guidelines on home oxygen use in adults. Thorax.
2015;70(6):589-591.
54. Fu S, Lv X, Fang Q, Liu Z. Oxygen therapy for acute myocardial infarction: A systematic
review and meta-analysis. Int J Nurs Stud. 2017;74:8-14.
55. Hofmann R, James SK, Jernberg T, et al; DETO2X–SWEDEHEART Investigators. Oxygen
therapy in suspected acute myocardial infarction. N Engl J Med. 2017;377(13):1240-
1249.
56. Huang HB, Peng JM, Weng L, et al. High-flow oxygen therapy in immunocompromised
patients with acute respiratory failure: A review and meta-analysis. J Crit Care.
2017;43:300-305.
57. Corley A, Rickard CM, Aitken LM, et al. High-flow nasal cannulae for respiratory support
in adult intensive care patients. Cochrane Database Syst Rev. 2017;5:CD010172.
58. Roffe C, Nevatte T, Sim J, et al; Stroke Oxygen Study Investigators and the Stroke
OxygenStudy Collaborative Group. Effect of routine low-dose oxygen supplementation
on death and disability in adults with acute stroke: The stroke oxygen study
randomized clinical trial. JAMA. 2017;318(12):1125-1135.
59. Ribeil JA, Labopin M, Stanislas A, et al. Transfusion-related adverse events are
decreased in pregnant women with sickle cell disease by a change in policy from
systematic transfusion to prophylactic oxygen therapy at home: A retrospective survey
by the international sickle cell disease observatory. Am J Hematol. 2018;93(6):794-802.
60. Wilfong A. Seizures and epilepsy in children: Initial treatment and monitoring.
UpToDate Inc., Waltham, MA. Last reviewed October 2018a.
61. Wilfong A. Seizures and epilepsy in children: Refractory seizures and prognosis.
UpToDate Inc., Waltham, MA. Last reviewed October 2018b.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and
constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or
program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any
results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna
or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be
updated and therefore is subject to change.
Copyright © 2001-2020 Aetna Inc.
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Clinical Policy Bulletins Medical Clinical Policy Bulletins

conditions are met:

and Review: 01/09/2020

provider or supplier of laboratory services, and History

period of acute illness or an exacerbation of their underlying disease, and Bulletin

A. Diagnosis of severe lung disease and qualifying lab values:**

B. Diagnosis of other hypoxia-related symptoms or ﬁndings with qualifying lab values:**

Erythrocytosis (hematocrit greater than 55 %)

C. Other diagnoses of hypoxia-related symptoms or ﬁndings with qualifying lab values:**

Although treatment of these diagnoses (pneumonia, asthma, croup, bronchitis) may

1. Resting (awake) PaO2 less than or equal to 55 mm Hg or arterial oxygen saturation

2. Resting PaO2 of 56 to 59 mm Hg or arterial oxygen saturation of 89 % at rest

Dependent edema suggesting congestive heart failure

3. Resting PaO2 greater than 59 mm Hg or oxygen saturation greater than 89 % only

1. During exercise: PaO2 less than or equal to 55 mm Hg or oxygen saturation less

a. PaO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal

IV. Oxygen Delivery Systems

The following delivery systems may be considered medically necessary:

Stationary: Oxygen concentrators, liquid reservoirs, or large cylinders (usually K or H

Portable Oxygen Concentrators: Portable oxygen concentrators and combination

Emergency or standby oxygen systems are considered not medically necessary.

Ambulatory oxygen systems and portable oxygen concentrators are considered not

Note: Except as noted in short-term indications, reassessment of oxygen needs through

Mehta et al (2013) stated that hypoxemia is an immediate consequence of obstructive sleep

Furthermore, UpToDate reviews on “Management of obstructive sleep apnea in adults” (Kryger

Acute Myocardial Infarction

Acute Respiratory Failure in Immunocompromised Individuals

Reduction of Transfusion-Related Adverse Events in Pregnant Women with Sickle Cell

Treatment of Pediatric Seizures

International Headache Society Diagnostic Criteria for Cluster Headache

The headaches must be accompanied by at least one of the following findings:

1. Ipsilateral conjunctival injection and/or lacrimation; or

6. A sense of restlessness or agitation

CPT Codes / HCPCS Codes / ICD-10 Codes

Code Code Description

Other CPT codes related to the CPB:

O2 saturation); with O2 saturation, by direct measurement, except pulse oximetry; or

gases, blood, O2 saturation only, by direct measurement, except pulse oximetry

94010 - 94777 Pulmonary medicine

respiratory assessment, apnea evaluation)

99504 Home visit for mechanical ventilation care

HCPCS codes covered if selection criteria are met:

E0424 Stationary compressed gaseous oxygen system, rental; includes container,

contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter,

humidifier, nebulizer, cannula or mask, and tubing

E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter,

humidifier, cannula or mask, and tubing

flowmeter, humidifier, cannula or mask, and tubing

oxygen containers, includes portable containers,regulator, flowmeter, humidifier,

flowmeter, humidifier, nebulizer, cannula or mask, and tubing

Code Code Description

indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

when no stationary gas or liquid system is used), 1 month's supply = 1 unit

stationary gas or liquid system is used), 1 month's supply = 1 unit

rest or nighttime exceeds 4 liters per minute (lpm)

E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or

greater oxygen concentration at the prescribed flow rate

oxygen concentration at the prescribed flow rate, each

E1392 Portable oxygen concentrator, rental

oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier,

cannula or mask, and tubing