01REQUIREMENTS: Documentation: the physician's prescription for home oxygen must include an estimate of the frequency, duration of use, duration of need, type of system to be used, and oxygen flow rate.
02A physician's statement of recent hospital test results is also acceptable, as is arterial oxygen saturation obtained by pulse oximetry.
03All qualification studies must be done while on room air unless medically contraindicated, and blood gas values can come from the doctor's office, a hospital, or an outpatient laboratory.
04Stationary systems are considered medically necessary for members who do not regularly go beyond the limits of a 50-ft tubing stationary system or who use oxygen only during sleep.
05Portable systems are considered medically necessary for members who occasionally go beyond those limits for less than 2 hours per day for most days of the week (minimum 2 hours per week), and preset portable oxygen units are considered not medically necessary.
06Ambulatory systems are considered medically necessary for members who regularly go beyond those limits for 2 hours or more per day for most days of the week (minimum 6 hours per week).
07Portable oxygen concentrators are considered medically necessary as an alternative to ambulatory systems only for members who meet the ambulatory criteria and are regularly (at least monthly) away from home for durations that exceed the capacity of ambulatory systems.
08For ongoing oxygen treatment, repeat qualifying lab values are reviewed on a monthly basis.
09Requests for more than episodic oxygen for pneumonia, asthma, croup or bronchitis are subject to medical review.
10Reassessment is required at 12 months after the start of therapy for members who qualify at an arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 %, and at 3 months after the start of therapy for members who qualify at an arterial PO2 of 56 to 59 mm Hg or an oxygen saturation of 89 % with dependent edema, P pulmonale, or erythrocythemia.
11Reassessments must be done by an Aetna participating oxygen-qualifying company that is in no way connected to the company supplying the oxygen therapy.
12The member's primary care and/or treating doctor must be notified for authorization of all testing and treatment changes, including discontinuation of coverage for oxygen therapy.
13A second (spare) oxygen tank is considered not medically necessary, except where the member is dependent on continuous oxygen.
14Duplicate oxygen systems are considered convenience items and not medically necessary.
15Rental of oxygen equipment, or purchase if less costly, is considered medically necessary when the selection criteria are met.
16Humidifiers for oxygen nasal cannula are not separately reimbursable.