Group I criteria include any of the following:
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or
- An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a patient who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake, or
- A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), or
- An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PQ 2 at or above 56 mm Hg or an arterial oxygen saturation at or above $9 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypaxemia that was demonstrated during exercise when the patient was breathing room air.
Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-Specified length of need, whichever is shorter. (Refer to the Documentation Section for information on recertification.)
Group II criteria include the presence of (a) an arterial PO2 of 56-59 mm Hg or an arterial blood oxygen saturation of 89 percent at rest (awake), during sleep for at least 5 minutes, or during exercise (as described under Group I criteria) and (b) any of the following:
- Dependent edema suggesting congestive heart failure, or
- Pulmonary hypertension or cor pulmanale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
- Erythrocythemia with a hematocrit greater than 56 percent. Initial coverage for patients meeting Group II criteria is limited to 3 months or the physician specified length of need, whichever is shorter. (Refer to the Documentation section for information on recertification.)
Group III includes patients with arterial PO2 levels at or above 60 mm Hg or arterial blood oxygen saturations at or above 90 percent. For these patients there is a rebuttable presumption of noncoverage.
For all the sleep oximetry criteria described above, the 5 minutes does not have to be continuous.
If all of the coverage conditions specified above are not met, the oxygen therapy will be denied as not medically necessary. Oxygen therapy will also be denied as not medically necessary if any of the following conditions are present:
- 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.
- Dyspnea without cor pulmonale or evidence of hypoxemia.
- 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.
- Terminal illnesses that do not affect the respiratory system.