CG-DME-18 Home Oxygen Therapy

Anthem CG-DME-18 addresses coverage for home oxygen therapy delivered in the home setting. It is medically necessary with qualifying laboratory evidence of hypoxemia for short-term use in acute conditions (for example, bronchiolitis, COPD exacerbation, pneumonia) and for long-term use in chronic hypoxemia from conditions such as bronchiectasis, chronic lung disease/COPD, cystic fibrosis, diffuse interstitial lung disease, pulmonary hypertension, pulmonary neoplasm, or recurring CHF due to chronic cor pulmonale. It is not medically necessary for severe peripheral vascular disease with isolated extremity desaturation without hypoxemia, terminal illness not affecting the respiratory system, angina or dyspnea without associated hypoxemia or cor pulmonale, or for preset regulators used with portable oxygen systems.

"Short term supplemental home oxygen therapy ismedically necessaryfor treatment of hypoxemia-related symptoms with qualifying laboratory values (seeNotebelow) associated with acute conditions includ..."