Prior Authorization Review Panel MCO Policy Submission · Emergency or standby oxygen systems are considered not medically necessary. Duplicate oxygen systems are considered convenience

Prior Authorization Review Panel MCO Policy Submission

A separate copy of this form must accompany each policy submitted for

review. Policies submitted without this form will not be considered for review.

Plan: Aetna Better Health Submission Date: 10/01/2018

Policy Number: 0002 Effective Date: Revision Date:

Policy Name: Oxygen

Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions

*All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below:

CPB 0002 Oxygen

Clinical content was last revised on 05/03/2016. Additional non-clinical updates were made by Corporate since the last PARP submission, as documented below.

Revision and Update History since last PARP submission: 02/14/2018 - This CPB has been updated with additional background information and references. 01/10/2019 – Next tentative scheduled review date by Corporate .

Name of Authorized Individual (Please type or print):

Dr. Bernard Lewin, M.D.

Signature of Authorized Individual:

www.aetnabetterhealth.com/pennsylvania Updated 02/14/2018

http://www.aetnabetterhealth.com/pennsylvania

Oxygen - Medical Clinical Policy Bulletins | Aetna Page 1 of 36

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Oxygen

Number: 0002 *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

Policy

I. Home oxygen therapy is only considered medically

necessary if all of the following conditions are met:

A. The treating physician has determined that

the member has a severe lung disease or hypoxia-

related symptoms that might be expected to

improve with oxygen therapy, and

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 provider or supplier of

laboratory services, and

D. The qualifying blood gas study was obtained under

the following conditions:

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

Policy His tory

Last Review

02/14/2018

Effective: 10/06/1995

Next

Review: 01/10/2019

Review History

Definitions

A dditiona l In form at ion

Clinical Policy

Bulletin Notes

http://aetnet.aetna.com/mpa/cpb/1_99/0002.html

http://www.aetna.com/)



2. If the qualifying blood gas study is not performed

during an inpatient hospital stay 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 period of acute illness or an

exacerbation of their underlying disease, and

E. Alternative treatment measures have been tried or

considered and deemed clinically ineffective.

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) 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”).


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.


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.

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,


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,


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,


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

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)

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)


capability, with back-up rate feature, used with

noninvasive interface, e.g., nasal or facial mask

(intermittent assist device with continuous



capability, with back-up rate feature, used with

invasive interface, e.g., tracheostomy tube

(intermittent assist device with continuous


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,

A37.81,

A37.91

Pneumonia in whooping cough

A48.1 Legionnaires' disease

B25.0 Cytomegaloviral pneumonitis

B44.0 Invasive pulmonary aspergillosis

B77.81 Ascariasis pneumonia

C34.00 - Malignant neoplasm of bronchus and lung

C34.92 C78.00 - Secondary malignant neoplasm of lung

C78.02 C94.00 - Acute erythroid leukemia

C94.02 D02.20 - Carcinoma in situ of bronchus and lung

D02.22 D14.30 - Benign neoplasm of bronchus and lung

D14.32

D45 Polycythemia vera

D56.0 -

D56.9

Thalassemia

D57.00 - Sickle-cell disorders

D57.219

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 - Cluster headaches

G44.029

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

J18.8 -

J18.9

Pneumonia

J40 - J42 Bronchitis and other chronic obstructive

J44.0 - pulmonary disease

J44.9

J45.20 -

J45.998

Asthma

J47.0 -

J47.9

Bronchiectasis

J84.10 Pulmonary fibrosis, unspecified




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


P27.0 -

P27.9

Chronic respiratory diseases originating in the

perinatal period

P29.30 - Persistent fetal circulation

P29.38

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): G43.001 - Migraine

G43.919

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]

Dyspnea [without cor pulmonale or evidence of

hypoxemia]

R06.00 -

R06.09




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.




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 © 2001-2018 Aetna Inc.


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number:

0002 Oxygen

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania Updated 02/14/2018

http://www.aetnabetterhealth.com/pennsylvania

Documents

Prior Authorization Review Panel MCO Policy Submission · Emergency or standby oxygen systems are considered not medically necessary. Duplicate oxygen systems are considered convenience