Home Oxygen Therapies

Summary of Medicare Part B Guidelines for Home Oxygen:

• Conditions for Which Oxygen Therapy May Be Covered:
  • Severe lung disease including COPD and ILD (regardless of known etiology), CF, bronchiectasis, widespread pulmonary neoplasms
  • Hypoxia related symptoms or findings expected to improve with O2: pulmonary hypertension, recurring CHF secondary to chronic cor pulmonale, erythrocytosis, impaired cognition, nocturnal restlessness, morning headache
• Qualifying Tests and Requirements:
  • Testing must be performed with a pt in chronic stable condition (i.e. outpatient clinic) or within two days of discharge from an inpatient hospital stay (after treatment of acute exacerbating conditions have been trialed, ie. infection, bronchospasm)
  • Medicare requires that test results must be documented in a pt’s medical record and made available to the oxygen provider 
• Patient can be tested under either of these conditions:
  • At rest: SpO2 ≤ 88% (or PaO2 <55)
  • If no hypoxia at rest, perform with exercise (“Ambulatory Sats”)
    • Ask RN or RT to perform and document in Epic—they have a template:  
      • SpO2 at rest
      • SpO2 on room air with ambulation (must desat ≤ 88%)
      • Amount of O2 (in L) required to maintain SpO2 > 89%
• Special Considerations:
  • Medicare requires an additional walk on 4L/min showing desaturation if the patient needs a flow rate of  5L/min or higher
  • Because of the risk of desaturation with exertion and the intrinsic error in the pulse ox (around 3%), patients with resting saturations of ≤ 92% should be walked to assess O2 needs
  • Be aware that if the patient has Raynaud’s or poor circulation, a finger pulse oximeter reading may be inaccurate and read lower than the patient’s actual saturations.  A head saturation monitor should be used in these circumstances
• Try to perform any of these diagnostic tests 1-2 days prior to anticipated discharge. Be sure to touch base with your CM about the need for home oxygen, as they will help arrange
• VA Specific Guidance: Will need to document ambulatory saturations in notes as above. Call the Oxygen Clinic (number listed in all team rooms) and talk with your case manager

Summary of Medicare Part C Guidelines for Home Respiratory Assist Devices i.e CPAP/BiPAP:

• Restrictive Thoracic Disorders: Covered if the following criteria are met:
  • There is documentation in the MR of a neuromuscular disease or a severe thoracic cage abnormality and one of the following:
    • An arterial blood gas PaCO2 ≥ 45mmHg, performed while awake and on home O2 requirement, OR
    • Sleep oximetry demonstrates oxygen saturation ≤ 88%, for ≥ 5 minutes of nocturnal recording time (minimum recording time of 2 hours), performed while on home O2 requirement, OR
    • For a neuromuscular disease (only), either:
      • Maximal inspiratory pressure < 60cm H2O or
      • Forced vital capacity < 50% predicted and
    • COPD may not contribute significantly to the patient’s limitations
• Severe COPD: Covered if the following criteria are met:
  • An arterial blood gas PaCO2 ≥ 52mmHg, performed while awake and on patient’s prescribed home O2
• Sleep oximetry demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time (minimum recording time of 2 hours), performed while breathing oxygen at 2LPM or patient’s prescribed FIO2 (whichever is higher), AND  
  • Prior to initiating therapy, sleep apnea and treatment with a continuous positive airway pressure (CPAP) device has been considered and ruled out (formal sleep testing not required)
• Hypoventilation Syndrome: covered if criteria 1, 2, AND either 3 or 4 are met:
  • An initial arterial blood gas PaCO2 ≥45 mm Hg, performed while awake and on home O2 requirement, AND
  • Spirometry shows an FEV1/FVC ≥ 70% AND
  • An arterial blood gas PaCO2, performed during sleep or immediately upon awakening that demonstrates worsening PaCO2 of ≥ 7mm Hg compared to the original result in criterion 1 OR
  • A facility-based PSG or HST demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time (minimum recording time of 2 hours) that is not caused by obstructive upper airway events, i.e., AHI <5
• OSA:
  • An initial screening for OSA in the hospital is nocturnal pulse oximetry. The distinct “saw-tooth” pattern representing intermittent hypoxia is suggestive of OSA, and a formal NPSG or home sleep test is recommended to evaluate for OSA.  This is done on an outpatient basis only once acute issues have fully resolved
  • Home CPAP/BiPAP covered IF:
    • The diagnosis of central sleep apnea or complex sleep apnea and
    • Significant improvement of the sleep-associated hypoventilation occurs with the use of the device