Medical Supplies and Equipment
Oxygen Therapy Benefits and Criteria

Oxygen Therapy Benefit Categories

• Oxygen Systems and Equipment; and
• Oxygen Supplies.

See the Oxygen Therapy Benefits and Criteria for a full list of eligible products, prior approval requirements and frequency limitations.

Prescriber/Provider Requirements

• Oxygen therapy benefits must be prescribed by a physician or medical specialist; and
• Oxygen therapy benefits must be provided by a recognized oxygen provider with appropriate health care staff and regulatory affiliations (registered respiratory therapist/registered nurse familiar with respiratory conditions).

Prior Approval Process

A prior approval is required for all oxygen therapy benefits. The provider must contact the First Nations and Inuit Health Branch (FNIHB) Regional Office to initiate the prior approval process. The Non-Insured Health Benefits Oxygen and Respiratory Program Prior Approval Form (PDF version) must be completed. In addition to the form, this documentation is required to support the request:

• The prescription;
• The arterial blood gas;
• The oximetry test; and
• Other supporting medical documentation (as required).

If a prior approval is granted, a PA number will be provided for billing purposes. Only then should the provider proceed with the fabrication/ fitting/dispensing of the item. If prior approval is not granted the provider will be advised of the reason.

On the prior approval form, providers are required to include a cost estimate of the delivery code 99400262.

Note to Ontario Providers: Providers must first contact the Ontario Home Oxygen Program of the Ontario Ministry of Health to access oxygen benefits for Ontario residents.

Exclusions

Exclusions are items that are not listed as benefits under the NIHB Program and are not available through the exception process. These items are therefore not considered for coverage under the NIHB Program and are not subject to the NIHB appeal process. Under the category of Oxygen Therapy Benefits, these include, but are not limited to

• Providing oxygen for indications which don't meet the medical criteria of the NIHB Program, for example, angina and pain relief (migraines).

Medical Guidelines for Authorizing Oxygen Equipment and Services

The applicant's condition must be stabilized and the treatment regimen optimized before long term oxygen therapy may be considered.

Qualifying medical indications are:

• A resting PaO2 on room air equal or less than 55 mm Hg;
• A resting PaO2 on room air between 56 and 59 mm Hg, when there is evidence of:
  • Cor pulmonale
  • Pulmonary hypertension
  • Secondary polycythemia
• Persistent PaO2 between 56 and 59 mm Hg, when there is evidence of:
  • Exercise limitation due to hypoxemia with significantly greater exercise capability and/or significantly decreased shortness of breath on oxygen compared to room air (confirmed by objective data);
  • Nocturnal hypoxemia when nocturnal oxygen desaturation is less than 88% for 30% of the night in spite of appropriate CPAP or bilevel therapy;
• New York Heart Association Stage IV Heart Disease with a confirmed diagnosis by a cardiologist and relevant symptomatology and test results; and
• Palliative care (prognosis of less than 3 months) with a clinical assessment by a physician demonstrating symptomatic benefit.

After three months and after one year of oxygen therapy for medical indications a and b an arterial blood gas on room air or, in exceptional circumstances, an oximetry test are required; for medical indications c, d, and e, an oximetry test is required.

Provider Services to Support Oxygen Therapy

• Set up must be completed within 24 hours (with the exception of ferry and remote site transportation limitations).
• Set up includes equipment delivery, safety and care of equipment, and education for the client on equipment use.
• Respiratory therapist (nurse) must visit within 72 hours, after 3 months and every 6 months thereafter to ensure optimum oxygen therapy (review prescription, review use of equipment, educate client on condition).

Quantity Limitations

Items that have an annual quantity limitation must be provided and billed for no more than a three-month period at a time. This applies to items claimed with or without a prior approval.

Oxygen Therapy Benefit List

Oxygen Systems and Equipment

Oxygen cylinder with content, regulator, holder, cart, shoulder pouch c/s straps

Additional oxygen cylinder without content, regulator, holder, cart, shoulder pouch

Oxygen Supplies

Disposables (Plastics)*

* If the oxygen system is rented the disposables are automatically included in the price of the rental. If the oxygen system is purchased the disposables may be billed only if they are not included in the maintenance agreement for oxygen system.

Gas content only (for cylinders)