OXYGEN THERAPY - Health Plan of Nevada

Oxygen Therapy of 12

OXYGEN THERAPY

Protocol: DME003

Effective Date: September 1, 2018

Table of Contents Page

COMMERCIAL & MEDICARE COVERAGE RATIONALE............................................................... 1 ADDITIONAL COMMERCIAL COVERAGE RATIONALE ............................................................... 7 MEDICAID COVERAGE RATIONALE ................................................................................................ 8

BACKGROUND ...................................................................................................................................... 9 REFERENCES ....................................................................................................................................... 11 PROTOCOL HISTORY/REVISION INFORMATION ........................................................................ 12

INSTRUCTIONS FOR USE

This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding

coverage, the enrollee specific document must be referenced. The terms of an enrollee's document

(e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event

of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first

identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage

prior to use of this Protocol. Other Policies and Coverage Determination Guidelines may apply.

UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and

Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute

medical advice. This policy does not govern Medicare Group Retiree members.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines,

to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in

connection with the independent professional medical judgment of a qualified health care provider and

do not constitute the practice of medicine or medical advice.

COMMERCIAL & MEDICARE COVERAGE RATIONALE

There are six National Coverage Determination and Local Coverage Determinations for Nevada

related to Oxygen: Home Use of Oxygen (NCD 240.2), Home Oxygen Use to Treat Cluster Headache

(NCD 240.2.2), Home Use of Oxygen in Approved Clinical Trials (NCD 240.2.1), Oxygen Treatment

of Inner Ear/Carbon Therapy (NCD 50.5), Hyperbaric Oxygen Therapy (NCD 20.29), and Oxygen and

Oxygen Equipment (L33797) (all accessed July 2017).

Home Use of Oxygen (NCD 240.2)

A. General

Medicare coverage of home oxygen and oxygen equipment under the durable medical equipment

(DME) benefit is considered reasonable and necessary only for patients with significant hypoxemia

who meet the medical documentation, laboratory evidence, and health conditions specified in

subsections B, C, and D. This section also includes special coverage criteria for portable oxygen

systems.


B. Medical Documentation:

The treating physicians prescription or other medical documentation must indicate that other forms of

treatment (e.g., medical and physical therapy directed at secretions, bronchospasm and infection) have

been tried, have not been sufficiently successful and oxygen therapy is still required. The physician’s

certification of medical necessity for oxygen equipment must include the results of specific testing

before coverage can be determined.

Initial claims for oxygen must be supported by medical information that specifies:

A diagnosis of the disease requiring home use of oxygen,

The oxygen flow rate,

An estimate of the frequency or duration of use (e.g., 2 liters per minutes, 10 minutes per hour,

12 hours per day),

Duration of need (e.g., 6 months or lifetime)

Evidence of qualifying test results done within 30 days before the initial date of service

Evidence of an in-person visit with a treating physician done within 30 days before the initial

date of service.

Note: A prescription for “oxygen PRN” or “oxygen as needed” does not meet the frequency/duration

of use requirement. Neither provides any basis for determining if the amount of oxygen is reasonable

and necessary for the patient.

C. Laboratory Evidence

Initial claims for oxygen therapy must also include the results of a blood gas study that has been

ordered and evaluated by the attending physician. This is usually in the form of a measurement of the

partial pressure of oxygen (PO2) in the arterial blood. A repeat arterial blood gas study is appropriate

when evidence indicates that an oxygen recipient has undergone a major change in their condition

relevant to home use of oxygen. Please see NCD for additional laboratory details, if needed.

D. Health Conditions

Coverage is available for patients with significant hypoxemia in the chronic stable state if:

1. The attending physician has determined that the patient has a health condition outlined in

subsection D.1 (below),

2. The patient meets the blood gas evidence requirements specified in subsection D.3 (below), and

3. The patient has appropriately tried other alternative treatment measures without complete

success.

1. Conditions for Which Oxygen Therapy May Be Covered A severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial

lung disease, whether of known or unknown etiology; cystic fibrosis, bronchiectasis;

widespread pulmonary neoplasm; or

Hypoxia-related symptoms or findings that might be expected to improve with oxygen

therapy. Examples of these symptoms and findings are pulmonary hypertension, recurring

congestive heart failure due to chronic cor pulmonale, erythrocytosis, impairment of the

cognitive process, nocturnal restlessness, and morning headache.


2. Conditions for Which Oxygen Therapy Is Not Covered 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;

Breathlessness without cor pulmonale or evidence of hypoxemia. Although intermittent

oxygen use is sometimes prescribed to relieve this condition, it is potentially harmful and

psychologically addicting;

Severe peripheral vascular disease resulting in clinically evident desaturation in one or

more extremities. There is no evidence that increased PO 2 improves the oxygenation of

tissues with impaired circulation; or

Terminal illnesses that do not affect the lungs.

3. Covered Blood Gas Values If the patient has a condition specified in subsection D.1 (above), the carrier must review the medical

documentation and laboratory evidence that has been submitted for a particular patient (see subsections

B and C) and determine if coverage is available under one of the three group categories outline below.

a) Group I criteria include any of the following:

An arterial PO 2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88

percent taken at rest, breathing room air.

An arterial PO 2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88

percent, taken during sleep for a patient who demonstrates an arterial PO 2 at or above 56

mm Hg or an arterial oxygen saturation at or above 89 percent while awake, or a greater

than normal fall in oxygen level during sleep (a decrease in arterial PO2 more than 10 mm

Hg, or decrease in arterial oxygen saturation more than 5 percent) associated with

symptoms of signs reasonable attributable to hypoxemia (e.g., impairment of cognitive

processes and nocturnal restlessness or insomnia). In hypoxemia (e.g., impairment of

cognitive processes and nocturnal restlessness or insomnia). In either of these cases,

coverage is provided only for use of oxygen during sleep, and then only one type of unit

will be covered. Portable oxygen therefore, would not be covered in this situation.

An arterial PO 2 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 PO 2 at or above 56

mm Hg or an arterial oxygen saturation at or above 89 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 hypoxemia that was demonstrated during exercise when the patient

was breathing room air.

b) Group II – Except as modified in subsection d, coverage is available for patients whose arterial PO2

is 56-59 mm Hg or whose arterial blood oxygen saturation is 89 percent, if there is evidence of:

Dependent edema suggesting congestive heart failure

Pulmonary hypertension or cor pulmonale, 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.

c) Group III – Except as modified in subsection d, carriers must apply a rebuttable presumption that a

home program of oxygen use is not medically necessary for patient with arterial PO2 levels at or


above 60 mm Hg, or arterial blood oxygen saturation at or above 90 percent. In order for claims in

this category to be reimbursed, the carrier’s reviewing physician needs to review any

documentation submitted in rebuttal of this presumption and grant specific approval of the claims.

CMS expects few claims to be approved for coverage in this category.

d) Variable Factors That May Affect Blood Gas Values – In reviewing the arterial PO2 levels and the

arterial oxygen saturation percentages specified in sub sections D.3.a, b and c, the carrier’s medical

staff must take into account variations in oxygen measurements that may result from such factors

as the patient’s age, the altitude level, or the patient’s decreased oxygen carrying capacity.

E. Portable Oxygen Systems:

A patient meeting the requirements specified below may quality for coverage of a portable oxygen

system either (1) by itself of (2) to use in addition to a stationary oxygen system. A portable

oxygen system is covered for a particular patient if:

The claim meets the requirements specified in subsections A-D, as appropriate; and

The medical documentation indicates that the patient is mobile in the home and would

benefit from the use of a portable oxygen system in the home. Portable oxygen systems are

not covered for patients who qualify for oxygen solely based on blood gas studies obtained

during sleep.

Oxygen and Oxygen Equipment (L33797) (partial LCD only; please see full LCD for additional

information on clinical studies, sleep studies and long-term oxygen therapy)

Portable Oxygen Systems

A portable oxygen system is covered if the beneficiary is mobile within the home and the qualifying

blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood

gas study was performed during sleep, portable oxygen will be denied as not reasonable and

necessary.

If coverage criteria are met, a portable oxygen system is usually separately payable in addition to the

stationary system.

Liter Flow Greater than 4 LPM

If basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow

rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while

the beneficiary is on 4 or more LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is

billed and the coverage criterion for the higher allowance is not met, payment will be limited to the

standard fee schedule allowance.

Miscellaneous:

Emergency or stand-by oxygen systems for beneficiaries who are not regularly using oxygen

will be denied as not reasonable and necessary since they are precautionary and not

therapeutic in nature.

Topical hyperbaric oxygen chambers (A4575) will be denied as not reasonable and

necessary.

Topical oxygen delivery systems (E0446) will be denied as not reasonable and necessary.


Please see LCD 33797 for additional information, if needed.

Home Oxygen Use to Treat Cluster Headaches (NCD 240.2.2):

Effective for claims with dates of services on or after January 4, 2011, the Centers for Medicare &

Medicaid Services (CMS) believes that the available evidence suggests that the home use of oxygen to

treat CH is promising and supports further research under §1862(a)(1)(E) of the Social Security Act

(the Act) through the Coverage With Study Participation (CSP) form of Coverage With Evidence

Development (CED).

The home use of oxygen to treat CH is covered by Medicare only for beneficiaries with CH

participating in an approved prospective clinical study comparing normobaric 100% oxygen (NBOT)

with at least one clinically appropriate comparator for the treatment of CH. See NCD for additional

details of the clinical study requirements.

Effective for claims with dates of service on and after January 4, 2011, CMS believes that the evidence

does not demonstrate that the home use of oxygen to treat CH improves health outcomes in Medicare

beneficiaries with CH. Therefore, the home use of oxygen to treat CH is not reasonable and

necessary under 1862(a)(1)(A) of the Act unless provided in the context of an approved clinical study

under CED (see above).

Home Use of Oxygen in Approved Clinical Trials (NCD 240.2.1)

The home use of oxygen is covered for those members with arterial oxygen partial pressure

measurements from 56 to 65 mm Hg or oxygen saturation at or above 89% who are enrolled subjects

in clinical trials approved by CMS and sponsored by the National Heart, Lung, and Blood Institute.

(NHLBI).

Oxygen Treatment of Inner Ear/Carbon Therapy (50.5)

Oxygen (95%) and carbon dioxide (5%) inhalation therapy for inner ear disease, such as

endolymphatic hydrops and fluctuant hearing loss, is not reasonable and necessary. The therapeutic

benefit deriving from this procedure is highly questionable.

Hyperbaric Oxygen Therapy (20.29)

A. Covered Conditions Program reimbursement for HBO therapy will be limited to that which is administered in a chamber

(including the one man unit) and is limited to the following conditions:

1. Acute carbon monoxide intoxication,

2. Decompression illness,

3. Gas embolism,

4. Gas gangrene,

5. Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used

in combination with accepted standard therapeutic measures when loss of function, limb, or life

is threatened.

6. Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy

would be an adjunctive treatment when loss of function, limb, or life is threatened.

7. Progressive necrotizing infections (necrotizing fasciitis),


8. Acute peripheral arterial insufficiency,

9. Preparation and preservation of compromised skin grafts (not for primary management of

wounds),

10. Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical

management,

11. Osteoradionecrosis as an adjunct to conventional treatment,

12. Soft tissue radionecrosis as an adjunct to conventional treatment,

13. Cyanide poisoning,

14. Actinomycosis, only as an adjunct to conventional therapy when the disease process is

refractory to antibiotics and surgical treatment,

15. Diabetic wounds of the lower extremities in patients who meet the following three criteria:

a. Patient has type I or type II diabetes and has a lower extremity wound that is due to

diabetes;

b. Patient has a wound classified as Wagner grade III or higher; and

c. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of

healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to

standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a

patient’s vascular status and correction of any vascular problems in the affected limb if possible,

optimization of nutritional status, optimization of glucose control, debridement by any means to

remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate

moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be

present. Failure to respond to standard wound care occurs when there are no measurable signs of

healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during

administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable

signs of healing have not been demonstrated within any 30-day period of treatment.

B. Noncovered Conditions All other indications not specified under §270.4(A) are not covered under the Medicare program. No

program payment may be made for any conditions other than those listed in §270.4(A).

No program payment may be made for HBO in the treatment of the following conditions:

1. Cutaneous, decubitus, and stasis ulcers.

2. Chronic peripheral vascular insufficiency.

3. Anaerobic septicemia and infection other than clostridial.

4. Skin burns (thermal).

5. Senility.

6. Myocardial infarction.

7. Cardiogenic shock.

8. Sickle cell anemia.

9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary

insufficiency.

10. Acute or chronic cerebral vascular insufficiency.

11. Hepatic necrosis.

12. Aerobic septicemia.


13. Nonvascular causes of chronic brain syndrome (Pick’s disease, Alzheimer’s disease,

Korsakoff’s disease).

14. Tetanus.

15. Systemic aerobic infection.

16. Organ transplantation.

17. Organ storage.

18. Pulmonary emphysema.

19. Exceptional blood loss anemia.

20. Multiple Sclerosis.

21. Arthritic Diseases.

22. Acute cerebral edema.

C. Topical Application of Oxygen This method of administering oxygen does not meet the definition of HBO therapy as stated above.

Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be

made for the topical application of oxygen.

For Medicare and Medicaid Determinations Related to States Outside of Nevada:

Please review Local Coverage Determinations that apply to other states outside of Nevada.

http://www.cms.hhs.gov/mcd/search

Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage

database on the Centers for Medicare and Medicaid Services’ Website.

ADDITIONAL COMMERCIAL COVERAGE RATIONALE

The following is additional clarification for Commercial members.

Liquid Oxygen (E0439)

Liquid Oxygen is a non-preferred item. The prescribing physician must provide justification that

liquid oxygen would provide superior benefit over standard gaseous system.

Portable Oxygen Systems: (E0431 and E1392)

A standard portable oxygen system (E0431) is covered if the patient is mobile within the home and the

qualifying blood gas study was performed while at rest (awake) or during exercise. If the only

qualifying blood gas study was performed during sleep, portable oxygen will be denied as not

reasonable and necessary.

A portable oxygen concentrator (E1392) will be considered based on a specific medical need and will

not be considered simply for convenience.

If coverage criteria are met, a portable oxygen system is usually separately payable in

addition to the stationary system.

If a portable oxygen system is covered, the supplier must provide whatever quantity of

oxygen the patient uses; reimbursement is the same, regardless of the quantity of oxygen

dispensed.

http://www.cms.hhs.gov/mcd/search


Oxygen System Approval, as prioritized, is as follows:

Oxygen System Home Environment

1. Standard E-tank with extended length

tubing (weight - approximately 15

pounds)

Environment is such that tank does not have to be

moved (e.g., small home).

Patient is safely mobile within home with

extended tubing (50 feet) or

Patient is physically able to maneuver E-tank in

the home.

2. M6-tank with or without conserving

device (weight – approximately 8

pounds)

Environment is such that tank must be moved

about in the home.

Patient must be able to maneuver 8 pound

cylinder tank (e.g., does not use walker)

3. Other Portable Oxygen

(weight – approximately 4- 8 pounds) Environment is such that oxygen system must be

moved about in the home.

Patient is unable to maneuver cylinder tank (e.g.,

uses walker)

MEDICAID COVERAGE RATIONALE

Medicaid Services Manual, Appendix B (accessed July 2018)

Oxygen (O2): Concentrators, Portables, Regulators, O2 Carts

Required Documentation:

Prescription and/or MD signed Prior Authorization/CMN Form

Oximetry spot check or overnight tape results.

Medical documentation supporting Qualifying Factors.

Oximetry test must be performed by a physician or qualified laboratory. O2 saturations (sats)

will not be accepted from an oxygen supplier.

Qualifying Factors:

1. Arterial blood gases or an ear oximetry reporting:

PO2 level of 60 mmHG or less on room air; or

80 mmHG or less on O2, or

O2 saturation (sat) level of 89% or less; and

medical necessity;

must list conditions of study (rest, sleeping, exercising, room air, on oxygen).

2. Children: 92% or less room air saturation, at rest.

3. O2 sats must be performed within 60 days of requested dates of service.

Liquid oxygen and related equipment are non-covered Medicaid services unless recipient does not

have electrical utilities at residence. Reimbursement will be only for stationary at the same rate of

concentrator.

Medicaid Services Manual, Attachment A, Policy #6-03 (accessed July 2018)

Outpatient Hospital Based Hyperbaric Oxygen Therapy


COVERAGE AND LIMITATIONS

Wound Therapy

1. Approval will be restricted to requests documenting that the wound has not responded to

conventional treatments as outlined in the Wound Management Policy (6-02), and initiated by a

physician. Attach a copy of the physician’s order to the request for treatment.

Maximum numbers of treatments authorized on consecutive days are 45. Therapy is conducted

once or twice daily for a maximum of 2 hours each treatment.

2. HBOT must be provided and attended by an HBOT physician. Reimbursement will be limited to

therapy provided in a chamber (including the one person unit). No payment will be made for

topical HBOT, or for other than the covered diagnosis.

3. Diabetic wounds of the lower extremities in pateints who meet the following three criteria:

a. Patient has Type I or Type II diabetes and has a lower extremity wound that is due to diabetes;

b. Patient has wound classified as Wagner grade III or higher;

c. Patient has failed an adequate course of standard wound therapy.

BACKGROUND

A standard preparation for oxygen used as a medicinal gas in conditions in which there is insufficient

oxygen carried by the blood to the tissues. Oxygen may be administered by mask, nasal tube, or tent

with adequate humidification.

Standard portable oxygen (not a portable oxygen concentrator) is an oxygen tank on wheels (E tank).

This delivery system is difficult to maneuver if the patient is also utilizing a walker for ambulation.

Since the flow of oxygen is continuous, 75% of the oxygen is wasted. Many patients will restrict their

activities due to difficulty maneuvering the tank. At 2 liters, the tank will last around 3.5 to 4 hours. A

smaller tank is available (M6). This tank is more portable than the E tank and allows greater mobility;

it is often used with an oxygen conserving device.

The larger E tank is pictured on the left compared to the smaller M6 tank on the right.

The oxygen conserving device (OCD) (E0431) is primarily for conservation of oxygen by providing a

bolus or volume of oxygen during the inspiratory phase of a typical breathing cycle. This bolus is

provided to a patient with a respiratory disorder as a supplemental source of breathing oxygen.


An oxygen conserving device dramatically extends the use time from a supply of oxygen, offering

increased mobility with improved comfort and increased efficiency. The reliability and safety of pulse

dose oxygen delivery has been proven effective in clinical testing as well as through independent tests

performed by physicians and respiratory therapists. The concept is based on the fact that the normal

breathing pattern is inhalation for one-third of the time, and exhalation about two-thirds of the time. As

a result, an oxygen conserving device extends the use time of an oxygen system by an average of 3:1.

The device senses the start of inhalation and instantly releases a short “pulsed” dose at the very

beginning of the breathing cycle. Since all of the “pulsed” oxygen finds its way deep into the lungs,

less oxygen is required to accomplish the same effect than with traditional continuous flow oxygen

systems. This means that an oxygen conserving device in pulse dose mode will last two to four times

longer than a continuous flow oxygen system, yet still provide the same therapeutic benefit. An M6

tank at 2 liters will last about 5 hours. Of note: it takes a great deal of strength to change out the tanks

on this item. Cost for this item is approximately $20/month.

A standard oxygen concentrator is for home use and has the advantage of being a continuous supply

of oxygen without the need for additional deliveries of bulky cylinders. They are approximately 20 X

30 inches in side and come with 50 feet of tubing. They are for home use only.

A portable oxygen concentrator (POC) (E1392) is a portable device used to provide oxygen therapy

to a patient at substantially higher concentrations than the levels of ambient air. It is very similar to a

home oxygen concentrator but it smaller in size and more mobile. The portable oxygen concentrator

makes it easy for patients to travel freely; they are small enough to fit in a car and many of the major

concentrators are now FAA approved. Most of the portable oxygen concentrator systems available

today provide oxygen on demand delivery in order to maximize the purity of the oxygen. They are not

limited to the amount of oxygen they can supply, making them ideal for use on long-haul journeys.

Price of this item is approximately $2,200. Rental for a week is approximately $100.

http://www.healthoxygen.com/airsep-newlife-intensity-10lpm-df-om-ltot-oxygen-concentrator.html


REFERENCES

Center for Medicare & Medicaid Services; NCD 240.2 Home Use of Oxygen, accessed July 2018.

Center for Medicare & Medicaid Services; NCD 240.2.1 Home Use of Oxygen in Approved Clinical

Trials. Accessed July 2018.

Center for Medicare & Medicaid Services; NCD 240.2.2 Home Oxygen Use to Treat Cluster

Headache. Accessed July 2018.

Center for Medicare & Medicaid Services; NCD 50.5 Oxygen Treatment of Inner Ear/Carbon Therapy.

Accessed July 2018.

Center for Medicare & Medicaid Services: NCD 20.29 Hyperbaric Oxygen Therapy. Accessed July

2018.

Noridian Services: Local Coverage Determination for Nevada Oxygen and Oxygen Equipment

(L33793) Accessed July 2018.

Nevada Medicaid Service Manual, Attachment A, Policy #6-03 Outpatient Hospital Based Hyperbaric

Oxygen Therapy. Accessed July 2017.

Nevada Medicaid Service Manual, Appendix B Respiratory Services Equipment or Item: Oxygen.

Accessed July 2018.

Qaseem A, et al. Diagnosis and management of stable chronic obstructive pulmonary disease: a

clinical practice guideline from the American College of Physicians. Annals of Internal Medicine

2007;147(9):633-8.

Wilt TJ, Niewoehner D, MacDonald R, Kane RL. Management of stable chronic obstructive

pulmonary disease: a systematic review for a clinical practice guideline. Annals of Internal Medicine

2007;147(9):639-53.

Bradley JM, Lasserson T, Elborn S, Macmahon J, O'neill B. A Systematic Review of Randomized

Controlled Trials Examining the Short-term Benefit of Ambulatory Oxygen in COPD. Chest

2007;131(1):278-85. DOI: 10.1378/chest.06-0180.

http://www.healthoxygen.com/inogen-one-g3-lightweight-4lpm-portable-oxygen-concentrator.html


Alam S, Palevsky HI. Standard therapies for pulmonary arterial hypertension. Clinics in Chest

Medicine 2007;28(1):91-115, viii. DOI: 10.1016/j.ccm.2006.12.003.

Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database of

Systematic Reviews 2008, Issue 3. Art. No.: CD004769. DOI: 10.1002/14651858.CD004769.pub2.

PROTOCOL HISTORY/REVISION INFORMATION

Date Action/Description

07/26/2018

07/27/2017

08/25/2016

08/27/2015

05/22/2014

01/24/2013

10/27/2011

02/24/2011

01/08/2010

Corporate Medical Affairs Committee

OXYGEN THERAPY - Health Plan of Nevada

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