Home Oxygen Therapies

Mackenzie Samson

Summary of Medicare Part B Guidelines for Home Oxygen

  • Conditions for which oxygen therapy may be covered
    • Severe lung disease including COPD and ILD, CF, bronchiectasis, widespread neoplasms
    • Hypoxia related symptoms or findings expected to improve with O2: pulmonary hypertension, cor pulmonale, erythrocytosis, impaired cognition, nocturnal restlessness, morning headache
  • Qualifying Tests and Requirements:
    • Testing must be performed with a pt in chronic stable condition or within two days of discharge from an inpt hospital stay (after treatment of acute exacerbating conditions)
    • Criteria: Resting SpO2 ≤ 88% (or PaO2 <55) or SpO2 <88% with ambulation
      • Must be documented in chart
  • Special Considerations:
    • Medicare requires an additional walk on 4L/min showing desaturation if the pt 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%), pts with resting SpO2 ≤ 92% should have amb sats checked
    • Pts with Raynaud’s or poor circulation may have inaccurate finger pulse oximeter readings. Consider using a head saturation monitor
  • 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:
    • Documentation of a neuromuscular disease/severe thoracic cage abnormality AND one of the following:
      • PaCO2 ≥ 45 mmHg on ABG, performed while awake and on home O2 requirement
      • Sleep oximetry demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time performed while on home O2 requirement
      • For a neuromuscular disease (only), either: Maximal inspiratory pressure < 60cm H2O or forced vital capacity < 50% predicted and COPD may not contribute significantly
  • Severe COPD, covered if the following criteria are met:
    • PaCO2 ≥ 52 mmHg on ABG, performed while awake and on pt’s prescribed home O2
    • Sleep oximetry demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time, performed while breathing oxygen at 2LPM or pt’s prescribed FiO2 (whichever is higher). Also requires that OSA had been considered and ruled out (formal sleep testing not required)
  • Hypoventilation Syndrome: covered if criteria 1, 2, AND either 3 or 4 are met:
    • PaCO2 ≥45 mmHg on ABG, performed while awake and on home O2 requirement, AND
    • Spirometry shows an FEV1/FVC ≥ 70% AND
    • ABG PaCO2, performed during sleep or immediately upon awakening that demonstrates worsening PaCO2 of ≥ 7 mmHg 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 that is not caused by obstructive upper airway events
  • OSA
    • An initial screening for OSA in the hospital is nocturnal pulse oximetry. The distinct “sawtooth” 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 outpt 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
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