Aetna · Clinical coverage policy

Aetna Oxygen coverage criteria

Aetna CPB 0002 covers home oxygen and oxygen-delivery equipment as medically necessary for members with severe lung disease or hypoxia-related conditions whose qualifying blood gas/oximetry study (done on room air, in a chronic stable state) meets defined thresholds — chiefly resting PaO2 ≤55 mm Hg or oxygen saturation ≤88%, or PaO2 56-59 mm Hg / saturation 89% with cor pulmonale, edema, or erythrocythemia. The delivery system (stationary, portable, ambulatory, or portable concentrator) is matched to the member's mobility and the 50-foot tubing limit, with reassessment at 3 or 12 months. Oxygen is not covered for non-hypoxemic conditions (e.g., angina or dyspnea without hypoxemia) and is considered experimental/investigational for migraine, pediatric seizures, prophylaxis in pregnant sickle-cell patients, and high-flow oxygen for home use.

Policy CPB 0002 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0002

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0002 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Oxygen (CPT E0424), and what gets it denied?

Path
Aetna CPB 0002 covers home oxygen and oxygen-delivery equipment as medically necessary for members with severe lung disease or hypoxia-related conditions whose qualifying blood gas/oximetry study (done on room air, in a chronic stable state) meets defined thresholds — chiefly resting PaO2 ≤55 mm Hg or oxygen saturation ≤88%, or PaO2 56-59 mm Hg / saturation 89% with cor pulmonale, edema, or erythrocythemia. The delivery system (stationary, portable, ambulatory, or portable concentrator) is matched to the member's mobility and the 50-foot tubing limit, with reassessment at 3 or 12 months. Oxygen is not covered for non-hypoxemic conditions (e.g., angina or dyspnea without hypoxemia) and is considered experimental/investigational for migraine, pediatric seizures, prophylaxis in pregnant sickle-cell patients, and high-flow oxygen for home use. Coverage criteria include: Home oxygen is medically necessary when ALL of the following are met: (1) the treating physician has determined the member has severe lung disease or hypoxia-related symptoms expected to improve with oxygen therapy; AND (2) the member's blood gas study meets the qualifying criteria stated in the policy; AND (3) the qualifying blood gas study was performed by a physician or qualified provider/supplier of laboratory services; AND (4) the qualifying study was obtained under the required conditions (see timing of study criterion); AND (5) alternative treatment measures have been tried or considered and deemed clinically ineffective.; Timing/conditions of the qualifying blood gas study (ONE of): if obtained during an inpatient hospital stay, the test must be obtained closest to but no earlier than 2 days prior to hospital discharge; OR if not during an inpatient stay (chronic conditions), the test must be performed while the member is in a chronic stable state — NOT during an acute illness or exacerbation. All qualification studies must be done on room air UNLESS medically contraindicated.; Covered diagnoses — severe lung disease with hypoxemia (any of), when qualifying blood gas values are met: bronchiectasis; COPD with severe hypoxemia; cystic fibrosis; diffuse interstitial lung disease; pediatric bronchopulmonary dysplasia (BPD); widespread pulmonary neoplasm.; Covered diagnoses — other hypoxia-related conditions (any of), when qualifying blood gas values are met: erythrocytosis (hematocrit >55%); pulmonary hypertension; recurring congestive heart failure due to chronic cor pulmonale.; Short-term conditions (asthma, bronchitis, croup, pneumonia): home oxygen is medically necessary generally for less than 1 month duration; ongoing/continued therapy beyond the short term requires repeat qualifying laboratory values on a monthly basis and medical review (absent special circumstances).; Cluster headaches (individual case-by-case review): medically necessary when the member meets International Headache Society diagnostic criteria AND is refractory to prescription medications. Diagnostic criteria require at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each accompanied by at least ONE ipsilateral cranial autonomic finding (conjunctival injection/lacrimation, nasal congestion/rhinorrhea, eyelid edema, forehead/facial sweating, miosis/ptosis, or restlessness/agitation).; Hemoglobinopathies (e.g., sickle cell disease): self-administration of adjunctive short-term oxygen therapy in the outpatient setting is medically necessary during a vaso-occlusive crisis exacerbated by hypoxia.; Infants with bronchopulmonary dysplasia (BPD) with variable oxygen needs: consideration on a case-by-case basis may be required in the absence of documentation of otherwise qualifying oxygen saturation values.; Obstructive sleep apnea (OSA) with hypoxemia — medically necessary when ALL of the following are met: (1) the member underwent a titration of at least 2 hours to determine optimal PAP settings, demonstrated by AHI/RDI reduced to an average of ≤10 events per hour, OR (if the initial AHI/RDI was <10 events per hour) the titration shows further reduction; AND (2) nocturnal oximetry for oxygen qualification was performed AFTER optimal PAP settings were determined and while the member was using PAP at those settings; AND (3) a qualifying oxygen saturation test was obtained during a titration polysomnographic study (split-night or stand-alone); AND (4) nocturnal oximetry conducted during the polysomnographic study demonstrates an oxygen saturation ≤88%.; Qualifying lab values — CONTINUOUS oxygen (ONE of): resting (awake) PaO2 ≤55 mm Hg OR arterial oxygen saturation ≤88%; OR resting PaO2 56-59 mm Hg OR oxygen saturation 89% (at rest awake, during sleep for ≥5 minutes, or during exercise) IN THE PRESENCE OF ANY of — dependent edema suggesting congestive heart failure, erythrocythemia (hematocrit >56%), or pulmonary hypertension/cor pulmonale (measured by pulmonary artery pressure, gated blood pool scan, echocardiogram, or P pulmonale on EKG with P wave >3 mm in standard leads II, III, aVF); OR resting PaO2 >59 mm Hg OR oxygen saturation >89% ONLY with additional documentation justifying the prescription and a summary of failed conservative therapy.; Qualifying lab values — NON-CONTINUOUS oxygen during EXERCISE: PaO2 ≤55 mm Hg OR oxygen saturation ≤88% with a low level of exertion; oxygen is medically necessary if documentation shows that use of oxygen improves the hypoxemia demonstrated during exercise on room air.; Qualifying lab values — NON-CONTINUOUS oxygen during SLEEP (ONE of): PaO2 ≤55 mm Hg OR oxygen saturation ≤88% for ≥5 minutes; OR a decrease in PaO2 of >10 mm Hg or a decrease in oxygen saturation of >5% from baseline for ≥5 minutes during sleep, associated with symptoms (cognitive impairment, nocturnal restlessness, insomnia) or signs (cor pulmonale, P pulmonale on EKG, documented pulmonary hypertension, erythrocytosis) reasonably attributable to hypoxemia.; Stationary oxygen systems (oxygen concentrators, liquid reservoirs, large cylinders K or H size): medically necessary for members who do not regularly go beyond the 50-foot tubing limit or who use oxygen only during sleep.; Portable oxygen systems (≥10 lbs, designed for transportation but not easily carried, e.g., a stroller with a steel cylinder): medically necessary for members who occasionally exceed the 50-foot tubing limit for less than 2 hours per day on most days (minimum 2 hours per week).; Ambulatory oxygen systems (<10 lbs when filled, designed to be carried, lasting ≥4 hours at 2 L/min continuous flow, e.g., liquid refillable or lightweight cylinders with/without conserving devices): medically necessary for members who regularly exceed the 50-foot tubing limit ≥2 hours per day on most days (minimum 6 hours per week); prescribed based on activity status.; Portable oxygen concentrators: medically necessary as an alternative to ambulatory systems when the member meets BOTH — (1) meets the criteria for ambulatory oxygen systems; AND (2) is regularly (at least monthly) away from home for periods exceeding the capacity of an ambulatory system.; Spare/second oxygen tank: a single spare tank may be medically necessary for a member who is dependent on continuous oxygen / dependent on an oxygen concentrator.; High-flow oxygen: medically necessary for acute hypoxic respiratory failure in hospitalized persons.; Airline oxygen tank rental: medically necessary when the member meets the criteria for home oxygen AND cannot use their own portable oxygen on the plane.; Rental versus purchase: rental — or purchase if it is less costly — of oxygen equipment is medically necessary when the selection criteria are met. The reasonable useful lifetime for oxygen equipment is 5 years from the initial date of service.; Reassessment (ONE of, based on initial qualifying values): required at 12 months after initiation for members with PaO2 ≤55 mm Hg or oxygen saturation ≤88%; required at 3 months after initiation for members with PaO2 56-59 mm Hg or oxygen saturation 89% accompanied by dependent edema, P pulmonale, or erythrocythemia. Reassessment must be performed by an independent (Aetna-participating) respiratory provider not connected to the supplying company, and the member's primary/treating physician must be notified for authorization. Additional reassessments may be requested at any time at the discretion of Aetna.. Applies to 21 codes: E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0444, E0447, E1390, E1391, E1392, K0738, 82803, 94010, 94060, 94760, 94761.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: A prescription written by the physician.; An estimate of the frequency of use, duration of use, and duration of need.; The type of oxygen delivery system to be used.; The oxygen flow rate.; The physician's statement of recent hospital test results OR arterial oxygen saturation obtained by pulse oximetry.; Qualifying blood gas study results performed by a physician or qualified provider/supplier of laboratory services (room air unless medically contraindicated; inpatient test no earlier than 2 days before discharge; chronic-condition test in a chronic stable state).; For cluster headache: documentation of at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each with at least one ipsilateral cranial autonomic finding, plus documentation of refractoriness to prescription medications.; For PaO2 >59 mm Hg / oxygen saturation >89% prescriptions: additional documentation justifying the prescription and a summary of failed conservative therapy.; At reassessment: documentation/notification of the member's primary/treating physician for authorization to continue oxygen.
Trap
Policy exclusions and limitations: Not medically necessary: angina pectoris in the absence of hypoxemia.; Not medically necessary: dyspnea without cor pulmonale or evidence of hypoxemia.; Not medically necessary: severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia.; Not medically necessary: terminal illnesses that do not affect the respiratory system.; Not medically necessary: ongoing/continued home oxygen for short-term conditions (asthma, bronchitis, croup, pneumonia) absent special circumstances and absent repeat monthly qualifying laboratory values.; Experimental, investigational, or unproven: home oxygen for the treatment of migraine headaches.; Experimental, investigational, or unproven: home oxygen for the treatment of pediatric seizures.; Experimental, investigational, or unproven: prophylactic home oxygen to reduce transfusion-related adverse events in pregnant women with sickle cell disease.; Experimental, investigational, or unproven: high-flow oxygen for home use.; Not medically necessary equipment: preset portable oxygen units.; Not medically necessary equipment: a second oxygen tank (spare tank), except where the member is dependent on continuous oxygen.; Not medically necessary equipment: emergency or standby oxygen systems.; Not medically necessary equipment: duplicate oxygen systems (convenience items), including having both a stationary and a portable concentrator, or both a transfilling system and a portable system.; Not separately reimbursable: humidifiers (e.g., Vapotherm) for an oxygen nasal cannula.; Not covered as DME: electrical generators (do not meet the definition of durable medical equipment because they are not primarily medical in nature).; Not medically necessary: ambulatory oxygen systems and portable oxygen concentrators for members who qualify solely on the basis of sleep blood gas studies. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0002 — Oxygen

Coverage criteria

  • Home oxygen is medically necessary when ALL of the following are met: (1) the treating physician has determined the member has severe lung disease or hypoxia-related symptoms expected to improve with oxygen therapy; AND (2) the member's blood gas study meets the qualifying criteria stated in the policy; AND (3) the qualifying blood gas study was performed by a physician or qualified provider/supplier of laboratory services; AND (4) the qualifying study was obtained under the required conditions (see timing of study criterion); AND (5) alternative treatment measures have been tried or considered and deemed clinically ineffective.
  • Timing/conditions of the qualifying blood gas study (ONE of): if obtained during an inpatient hospital stay, the test must be obtained closest to but no earlier than 2 days prior to hospital discharge; OR if not during an inpatient stay (chronic conditions), the test must be performed while the member is in a chronic stable state — NOT during an acute illness or exacerbation. All qualification studies must be done on room air UNLESS medically contraindicated.
  • Covered diagnoses — severe lung disease with hypoxemia (any of), when qualifying blood gas values are met: bronchiectasis; COPD with severe hypoxemia; cystic fibrosis; diffuse interstitial lung disease; pediatric bronchopulmonary dysplasia (BPD); widespread pulmonary neoplasm.
  • Covered diagnoses — other hypoxia-related conditions (any of), when qualifying blood gas values are met: erythrocytosis (hematocrit >55%); pulmonary hypertension; recurring congestive heart failure due to chronic cor pulmonale.
  • Short-term conditions (asthma, bronchitis, croup, pneumonia): home oxygen is medically necessary generally for less than 1 month duration; ongoing/continued therapy beyond the short term requires repeat qualifying laboratory values on a monthly basis and medical review (absent special circumstances).
  • Cluster headaches (individual case-by-case review): medically necessary when the member meets International Headache Society diagnostic criteria AND is refractory to prescription medications. Diagnostic criteria require at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each accompanied by at least ONE ipsilateral cranial autonomic finding (conjunctival injection/lacrimation, nasal congestion/rhinorrhea, eyelid edema, forehead/facial sweating, miosis/ptosis, or restlessness/agitation).
  • Hemoglobinopathies (e.g., sickle cell disease): self-administration of adjunctive short-term oxygen therapy in the outpatient setting is medically necessary during a vaso-occlusive crisis exacerbated by hypoxia.
  • Infants with bronchopulmonary dysplasia (BPD) with variable oxygen needs: consideration on a case-by-case basis may be required in the absence of documentation of otherwise qualifying oxygen saturation values.
  • Obstructive sleep apnea (OSA) with hypoxemia — medically necessary when ALL of the following are met: (1) the member underwent a titration of at least 2 hours to determine optimal PAP settings, demonstrated by AHI/RDI reduced to an average of ≤10 events per hour, OR (if the initial AHI/RDI was <10 events per hour) the titration shows further reduction; AND (2) nocturnal oximetry for oxygen qualification was performed AFTER optimal PAP settings were determined and while the member was using PAP at those settings; AND (3) a qualifying oxygen saturation test was obtained during a titration polysomnographic study (split-night or stand-alone); AND (4) nocturnal oximetry conducted during the polysomnographic study demonstrates an oxygen saturation ≤88%.
  • Qualifying lab values — CONTINUOUS oxygen (ONE of): resting (awake) PaO2 ≤55 mm Hg OR arterial oxygen saturation ≤88%; OR resting PaO2 56-59 mm Hg OR oxygen saturation 89% (at rest awake, during sleep for ≥5 minutes, or during exercise) IN THE PRESENCE OF ANY of — dependent edema suggesting congestive heart failure, erythrocythemia (hematocrit >56%), or pulmonary hypertension/cor pulmonale (measured by pulmonary artery pressure, gated blood pool scan, echocardiogram, or P pulmonale on EKG with P wave >3 mm in standard leads II, III, aVF); OR resting PaO2 >59 mm Hg OR oxygen saturation >89% ONLY with additional documentation justifying the prescription and a summary of failed conservative therapy.
  • Qualifying lab values — NON-CONTINUOUS oxygen during EXERCISE: PaO2 ≤55 mm Hg OR oxygen saturation ≤88% with a low level of exertion; oxygen is medically necessary if documentation shows that use of oxygen improves the hypoxemia demonstrated during exercise on room air.
  • Qualifying lab values — NON-CONTINUOUS oxygen during SLEEP (ONE of): PaO2 ≤55 mm Hg OR oxygen saturation ≤88% for ≥5 minutes; OR a decrease in PaO2 of >10 mm Hg or a decrease in oxygen saturation of >5% from baseline for ≥5 minutes during sleep, associated with symptoms (cognitive impairment, nocturnal restlessness, insomnia) or signs (cor pulmonale, P pulmonale on EKG, documented pulmonary hypertension, erythrocytosis) reasonably attributable to hypoxemia.
  • Stationary oxygen systems (oxygen concentrators, liquid reservoirs, large cylinders K or H size): medically necessary for members who do not regularly go beyond the 50-foot tubing limit or who use oxygen only during sleep.
  • Portable oxygen systems (≥10 lbs, designed for transportation but not easily carried, e.g., a stroller with a steel cylinder): medically necessary for members who occasionally exceed the 50-foot tubing limit for less than 2 hours per day on most days (minimum 2 hours per week).
  • Ambulatory oxygen systems (<10 lbs when filled, designed to be carried, lasting ≥4 hours at 2 L/min continuous flow, e.g., liquid refillable or lightweight cylinders with/without conserving devices): medically necessary for members who regularly exceed the 50-foot tubing limit ≥2 hours per day on most days (minimum 6 hours per week); prescribed based on activity status.
  • Portable oxygen concentrators: medically necessary as an alternative to ambulatory systems when the member meets BOTH — (1) meets the criteria for ambulatory oxygen systems; AND (2) is regularly (at least monthly) away from home for periods exceeding the capacity of an ambulatory system.
  • Spare/second oxygen tank: a single spare tank may be medically necessary for a member who is dependent on continuous oxygen / dependent on an oxygen concentrator.
  • High-flow oxygen: medically necessary for acute hypoxic respiratory failure in hospitalized persons.
  • Airline oxygen tank rental: medically necessary when the member meets the criteria for home oxygen AND cannot use their own portable oxygen on the plane.
  • Rental versus purchase: rental — or purchase if it is less costly — of oxygen equipment is medically necessary when the selection criteria are met. The reasonable useful lifetime for oxygen equipment is 5 years from the initial date of service.
  • Reassessment (ONE of, based on initial qualifying values): required at 12 months after initiation for members with PaO2 ≤55 mm Hg or oxygen saturation ≤88%; required at 3 months after initiation for members with PaO2 56-59 mm Hg or oxygen saturation 89% accompanied by dependent edema, P pulmonale, or erythrocythemia. Reassessment must be performed by an independent (Aetna-participating) respiratory provider not connected to the supplying company, and the member's primary/treating physician must be notified for authorization. Additional reassessments may be requested at any time at the discretion of Aetna.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • A prescription written by the physician.
  • An estimate of the frequency of use, duration of use, and duration of need.
  • The type of oxygen delivery system to be used.
  • The oxygen flow rate.
  • The physician's statement of recent hospital test results OR arterial oxygen saturation obtained by pulse oximetry.
  • Qualifying blood gas study results performed by a physician or qualified provider/supplier of laboratory services (room air unless medically contraindicated; inpatient test no earlier than 2 days before discharge; chronic-condition test in a chronic stable state).
  • For cluster headache: documentation of at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each with at least one ipsilateral cranial autonomic finding, plus documentation of refractoriness to prescription medications.
  • For PaO2 >59 mm Hg / oxygen saturation >89% prescriptions: additional documentation justifying the prescription and a summary of failed conservative therapy.
  • At reassessment: documentation/notification of the member's primary/treating physician for authorization to continue oxygen.

Frequently asked questions

When does Aetna cover Oxygen (CPT E0424), and what gets it denied?
Aetna CPB 0002 covers home oxygen and oxygen-delivery equipment as medically necessary for members with severe lung disease or hypoxia-related conditions whose qualifying blood gas/oximetry study (done on room air, in a chronic stable state) meets defined thresholds — chiefly resting PaO2 ≤55 mm Hg or oxygen saturation ≤88%, or PaO2 56-59 mm Hg / saturation 89% with cor pulmonale, edema, or erythrocythemia. The delivery system (stationary, portable, ambulatory, or portable concentrator) is matched to the member's mobility and the 50-foot tubing limit, with reassessment at 3 or 12 months. Oxygen is not covered for non-hypoxemic conditions (e.g., angina or dyspnea without hypoxemia) and is considered experimental/investigational for migraine, pediatric seizures, prophylaxis in pregnant sickle-cell patients, and high-flow oxygen for home use. Coverage criteria include: Home oxygen is medically necessary when ALL of the following are met: (1) the treating physician has determined the member has severe lung disease or hypoxia-related symptoms expected to improve with oxygen therapy; AND (2) the member's blood gas study meets the qualifying criteria stated in the policy; AND (3) the qualifying blood gas study was performed by a physician or qualified provider/supplier of laboratory services; AND (4) the qualifying study was obtained under the required conditions (see timing of study criterion); AND (5) alternative treatment measures have been tried or considered and deemed clinically ineffective.; Timing/conditions of the qualifying blood gas study (ONE of): if obtained during an inpatient hospital stay, the test must be obtained closest to but no earlier than 2 days prior to hospital discharge; OR if not during an inpatient stay (chronic conditions), the test must be performed while the member is in a chronic stable state — NOT during an acute illness or exacerbation. All qualification studies must be done on room air UNLESS medically contraindicated.; Covered diagnoses — severe lung disease with hypoxemia (any of), when qualifying blood gas values are met: bronchiectasis; COPD with severe hypoxemia; cystic fibrosis; diffuse interstitial lung disease; pediatric bronchopulmonary dysplasia (BPD); widespread pulmonary neoplasm.; Covered diagnoses — other hypoxia-related conditions (any of), when qualifying blood gas values are met: erythrocytosis (hematocrit >55%); pulmonary hypertension; recurring congestive heart failure due to chronic cor pulmonale.; Short-term conditions (asthma, bronchitis, croup, pneumonia): home oxygen is medically necessary generally for less than 1 month duration; ongoing/continued therapy beyond the short term requires repeat qualifying laboratory values on a monthly basis and medical review (absent special circumstances).; Cluster headaches (individual case-by-case review): medically necessary when the member meets International Headache Society diagnostic criteria AND is refractory to prescription medications. Diagnostic criteria require at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each accompanied by at least ONE ipsilateral cranial autonomic finding (conjunctival injection/lacrimation, nasal congestion/rhinorrhea, eyelid edema, forehead/facial sweating, miosis/ptosis, or restlessness/agitation).; Hemoglobinopathies (e.g., sickle cell disease): self-administration of adjunctive short-term oxygen therapy in the outpatient setting is medically necessary during a vaso-occlusive crisis exacerbated by hypoxia.; Infants with bronchopulmonary dysplasia (BPD) with variable oxygen needs: consideration on a case-by-case basis may be required in the absence of documentation of otherwise qualifying oxygen saturation values.; Obstructive sleep apnea (OSA) with hypoxemia — medically necessary when ALL of the following are met: (1) the member underwent a titration of at least 2 hours to determine optimal PAP settings, demonstrated by AHI/RDI reduced to an average of ≤10 events per hour, OR (if the initial AHI/RDI was <10 events per hour) the titration shows further reduction; AND (2) nocturnal oximetry for oxygen qualification was performed AFTER optimal PAP settings were determined and while the member was using PAP at those settings; AND (3) a qualifying oxygen saturation test was obtained during a titration polysomnographic study (split-night or stand-alone); AND (4) nocturnal oximetry conducted during the polysomnographic study demonstrates an oxygen saturation ≤88%.; Qualifying lab values — CONTINUOUS oxygen (ONE of): resting (awake) PaO2 ≤55 mm Hg OR arterial oxygen saturation ≤88%; OR resting PaO2 56-59 mm Hg OR oxygen saturation 89% (at rest awake, during sleep for ≥5 minutes, or during exercise) IN THE PRESENCE OF ANY of — dependent edema suggesting congestive heart failure, erythrocythemia (hematocrit >56%), or pulmonary hypertension/cor pulmonale (measured by pulmonary artery pressure, gated blood pool scan, echocardiogram, or P pulmonale on EKG with P wave >3 mm in standard leads II, III, aVF); OR resting PaO2 >59 mm Hg OR oxygen saturation >89% ONLY with additional documentation justifying the prescription and a summary of failed conservative therapy.; Qualifying lab values — NON-CONTINUOUS oxygen during EXERCISE: PaO2 ≤55 mm Hg OR oxygen saturation ≤88% with a low level of exertion; oxygen is medically necessary if documentation shows that use of oxygen improves the hypoxemia demonstrated during exercise on room air.; Qualifying lab values — NON-CONTINUOUS oxygen during SLEEP (ONE of): PaO2 ≤55 mm Hg OR oxygen saturation ≤88% for ≥5 minutes; OR a decrease in PaO2 of >10 mm Hg or a decrease in oxygen saturation of >5% from baseline for ≥5 minutes during sleep, associated with symptoms (cognitive impairment, nocturnal restlessness, insomnia) or signs (cor pulmonale, P pulmonale on EKG, documented pulmonary hypertension, erythrocytosis) reasonably attributable to hypoxemia.; Stationary oxygen systems (oxygen concentrators, liquid reservoirs, large cylinders K or H size): medically necessary for members who do not regularly go beyond the 50-foot tubing limit or who use oxygen only during sleep.; Portable oxygen systems (≥10 lbs, designed for transportation but not easily carried, e.g., a stroller with a steel cylinder): medically necessary for members who occasionally exceed the 50-foot tubing limit for less than 2 hours per day on most days (minimum 2 hours per week).; Ambulatory oxygen systems (<10 lbs when filled, designed to be carried, lasting ≥4 hours at 2 L/min continuous flow, e.g., liquid refillable or lightweight cylinders with/without conserving devices): medically necessary for members who regularly exceed the 50-foot tubing limit ≥2 hours per day on most days (minimum 6 hours per week); prescribed based on activity status.; Portable oxygen concentrators: medically necessary as an alternative to ambulatory systems when the member meets BOTH — (1) meets the criteria for ambulatory oxygen systems; AND (2) is regularly (at least monthly) away from home for periods exceeding the capacity of an ambulatory system.; Spare/second oxygen tank: a single spare tank may be medically necessary for a member who is dependent on continuous oxygen / dependent on an oxygen concentrator.; High-flow oxygen: medically necessary for acute hypoxic respiratory failure in hospitalized persons.; Airline oxygen tank rental: medically necessary when the member meets the criteria for home oxygen AND cannot use their own portable oxygen on the plane.; Rental versus purchase: rental — or purchase if it is less costly — of oxygen equipment is medically necessary when the selection criteria are met. The reasonable useful lifetime for oxygen equipment is 5 years from the initial date of service.; Reassessment (ONE of, based on initial qualifying values): required at 12 months after initiation for members with PaO2 ≤55 mm Hg or oxygen saturation ≤88%; required at 3 months after initiation for members with PaO2 56-59 mm Hg or oxygen saturation 89% accompanied by dependent edema, P pulmonale, or erythrocythemia. Reassessment must be performed by an independent (Aetna-participating) respiratory provider not connected to the supplying company, and the member's primary/treating physician must be notified for authorization. Additional reassessments may be requested at any time at the discretion of Aetna.. Applies to 21 codes: E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0440, E0441, E0444, E0447, E1390, E1391, E1392, K0738, 82803, 94010, 94060, 94760, 94761. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: A prescription written by the physician.; An estimate of the frequency of use, duration of use, and duration of need.; The type of oxygen delivery system to be used.; The oxygen flow rate.; The physician's statement of recent hospital test results OR arterial oxygen saturation obtained by pulse oximetry.; Qualifying blood gas study results performed by a physician or qualified provider/supplier of laboratory services (room air unless medically contraindicated; inpatient test no earlier than 2 days before discharge; chronic-condition test in a chronic stable state).; For cluster headache: documentation of at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each with at least one ipsilateral cranial autonomic finding, plus documentation of refractoriness to prescription medications.; For PaO2 >59 mm Hg / oxygen saturation >89% prescriptions: additional documentation justifying the prescription and a summary of failed conservative therapy.; At reassessment: documentation/notification of the member's primary/treating physician for authorization to continue oxygen. Policy exclusions and limitations: Not medically necessary: angina pectoris in the absence of hypoxemia.; Not medically necessary: dyspnea without cor pulmonale or evidence of hypoxemia.; Not medically necessary: severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia.; Not medically necessary: terminal illnesses that do not affect the respiratory system.; Not medically necessary: ongoing/continued home oxygen for short-term conditions (asthma, bronchitis, croup, pneumonia) absent special circumstances and absent repeat monthly qualifying laboratory values.; Experimental, investigational, or unproven: home oxygen for the treatment of migraine headaches.; Experimental, investigational, or unproven: home oxygen for the treatment of pediatric seizures.; Experimental, investigational, or unproven: prophylactic home oxygen to reduce transfusion-related adverse events in pregnant women with sickle cell disease.; Experimental, investigational, or unproven: high-flow oxygen for home use.; Not medically necessary equipment: preset portable oxygen units.; Not medically necessary equipment: a second oxygen tank (spare tank), except where the member is dependent on continuous oxygen.; Not medically necessary equipment: emergency or standby oxygen systems.; Not medically necessary equipment: duplicate oxygen systems (convenience items), including having both a stationary and a portable concentrator, or both a transfilling system and a portable system.; Not separately reimbursable: humidifiers (e.g., Vapotherm) for an oxygen nasal cannula.; Not covered as DME: electrical generators (do not meet the definition of durable medical equipment because they are not primarily medical in nature).; Not medically necessary: ambulatory oxygen systems and portable oxygen concentrators for members who qualify solely on the basis of sleep blood gas studies. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Oxygen?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: A prescription written by the physician.; An estimate of the frequency of use, duration of use, and duration of need.; The type of oxygen delivery system to be used.; The oxygen flow rate.; The physician's statement of recent hospital test results OR arterial oxygen saturation obtained by pulse oximetry.; Qualifying blood gas study results performed by a physician or qualified provider/supplier of laboratory services (room air unless medically contraindicated; inpatient test no earlier than 2 days before discharge; chronic-condition test in a chronic stable state).; For cluster headache: documentation of at least five severe to very severe unilateral headache attacks lasting 15-180 minutes when untreated, each with at least one ipsilateral cranial autonomic finding, plus documentation of refractoriness to prescription medications.; For PaO2 >59 mm Hg / oxygen saturation >89% prescriptions: additional documentation justifying the prescription and a summary of failed conservative therapy.; At reassessment: documentation/notification of the member's primary/treating physician for authorization to continue oxygen.
What does Aetna exclude for Oxygen?
Policy exclusions and limitations: Not medically necessary: angina pectoris in the absence of hypoxemia.; Not medically necessary: dyspnea without cor pulmonale or evidence of hypoxemia.; Not medically necessary: severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia.; Not medically necessary: terminal illnesses that do not affect the respiratory system.; Not medically necessary: ongoing/continued home oxygen for short-term conditions (asthma, bronchitis, croup, pneumonia) absent special circumstances and absent repeat monthly qualifying laboratory values.; Experimental, investigational, or unproven: home oxygen for the treatment of migraine headaches.; Experimental, investigational, or unproven: home oxygen for the treatment of pediatric seizures.; Experimental, investigational, or unproven: prophylactic home oxygen to reduce transfusion-related adverse events in pregnant women with sickle cell disease.; Experimental, investigational, or unproven: high-flow oxygen for home use.; Not medically necessary equipment: preset portable oxygen units.; Not medically necessary equipment: a second oxygen tank (spare tank), except where the member is dependent on continuous oxygen.; Not medically necessary equipment: emergency or standby oxygen systems.; Not medically necessary equipment: duplicate oxygen systems (convenience items), including having both a stationary and a portable concentrator, or both a transfilling system and a portable system.; Not separately reimbursable: humidifiers (e.g., Vapotherm) for an oxygen nasal cannula.; Not covered as DME: electrical generators (do not meet the definition of durable medical equipment because they are not primarily medical in nature).; Not medically necessary: ambulatory oxygen systems and portable oxygen concentrators for members who qualify solely on the basis of sleep blood gas studies. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0002 — Oxygen

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0002 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.