5.0 Oxygen equipment and supplies benefits list

Effective date: September 14, 2022

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5.1 General information

5.1.1 Benefit policies

General information common to all medical supplies and equipment (MS&E) can be found in the general policies.

5.1.1.1 General information

  • home oxygen may be considered for coverage by the NIHB program once the client's condition is stabilized and treatment regimen is optimized
  • coverage is authorized for the primary residence only, with the exception of additional oxygen requirements due to travel for the purpose of attending a medical appointment
  • while supplemental oxygen for the purpose of attending medical appointments is assessed on a case-by-case basis, it is expected that the client will use the oxygen concentrator when possible
  • NIHB covers oxygen portability away from the primary residence for the purpose of completing essential activities in the client's home and community, for example, shopping for groceries or personal items (up to 12 cylinders per month)
  • with medical justification, NIHB will consider additional portability (above 12 cylinders per month) on a case-by-case basis
  • NIHB expects that the provider will optimize the client's oxygen supply with the use of oxygen conserving devices (such as with an oxygen conservation device (OCD) for oxygen cylinders, or moustache or pendant style nasal cannulas)

Initially oxygen requests will be approved for a 3-month period. Following the 3-month period a second request will be approved with different documentation requirements for the next 9 months. After 12 months, oxygen will be renewed on an annual basis with prior approval request. Although arterial blood gas (ABG) assessment is not required, it may be requested to confirm eligibility.

5.1.2 Prescriber and provider requirements

Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the specific item as listed in the tables. Items that are prescribed by prescribers/recommenders not recognized by NIHB for the specific item will lead to denials or reversals of claims.

The following is a list of NIHB recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:

  • MD — Physician
  • NP — Nurse Practitioner
  • PA — Physician Assistant - (applies to Manitoba only)

The following is a list of NIHB recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:

  • GEN — Enrolled general medical supplies and equipment or pharmacy provider
  • OP — Oxygen Provider with required staff:
    • LPN/RPN — Licensed Practical Nurse/Registered Practical Nurse when within their scope of practice in their province/territory
    • RN — Registered Nurse
    • RRT — Registered Respiratory Therapist

5.1.3 Prior approval requirements

General prior approval requirements can be found in the general policies.

To initiate the prior approval process, the Oxygen Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following supporting documentation:

  • a prescription detailing the oxygen flow in litres per minute and usage in a number of hours per day signed and dated by an NIHB recognized prescriber for the requested benefit
  • testing information as listed in section 5.2 Oxygen equipment and devises including an arterial blood gas (ABG) results or 5-minute oximetry strips
  • any additional documentation to support the request
  • an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plan, etc.)
  • note: for a change in funded equipment or quantity, a written explanation from an RRT or RN is accepted

5.1.4 Exclusions

In addition to the general exclusion policy listed in the general policies, the following items are excluded from the oxygen benefit and are not considered for coverage or appeal under the NIHB program:

  • oxygen for therapy treatment and/or therapy equipment, including but not limited to:
    • pain relief (for example: migraines, cluster headaches, chronic fatigue syndrome)
    • topical or systemic hyperbaric treatment
    • oxygen for angina in the absence of documented chronic hypoxemia
  • oxygen benefits for outings while the client is an in-patient in an acute or long-term hospital setting
  • oxygen to run nebulizers/compressors
  • oxygen on a "stand-by basis" (PRN)

5.1.5 Warranties

Providers must honour the manufacturer's warranty.

5.1.6 Repairs

Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.

The following rules apply:

  • prior approval is required for repairs exceeding the unit price or frequency
  • request must include detailed cost breakdown of parts, labour time and rates
  • repairs must have a minimum warranty of 90 days

A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.

Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.

5.1.7 Replacement requirements

To be eligible for replacement the item must meet ONE of the following conditions:

  • be outside the recommended replacement guideline
  • not working, outside of warranty and the cost of repair exceeds the cost of a new item
  • the item no longer meets the client's needs due to a change in medical condition

All requests for replacement require a new prescription. If an item is required before the recommended replacement guidelines, documentation supporting the need for early replacement must be provided.

5.1.8 Services included in the price

The following services must be included in the price of the item to be considered for coverage:

  • complete set-up within 24 hours of authorization (with the exception of ferry and remote site transportation limitations)
  • equipment delivery, safety and care, and client education on use
  • a respiratory therapist or nurse visit within 72 hours, after three months, and every six months thereafter to ensure optimum oxygen therapy (for example: review prescription, review use of equipment, educate client on condition)
  • equipment must be removed as soon as feasible after being informed that it is no longer required

5.1.9 End of Supplemental Oxygen Therapy (rental)

When oxygen equipment is no longer required, the following rules apply:

  • a prescription to stop oxygen therapy is required unless the client is deceased. The provider should retain a copy of the prescription for their records
  • providers must inform the program (by call or fax) when supplemental oxygen is no longer required and submit the benefit end-date. Payment will be stopped on this date
  • claims submitted after the provider has been made aware that the client no longer requires the use of oxygen therapy and equipment are subject to recovery or reversal

5.1.10 Terminology

Item code

The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.

Prior approval

A program coverage confirmation is issued by a NIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program.

Recommended replacement guidelines

The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.

Unit price

Unit price information may be found on the price files, located on the Express Scripts Canada NIHB provider and client website.

5.2 Oxygen equipment and devices

5.2.1 Testing information

  • Arterial blood gas (ABG)* and its requirements:
    • ABGs are to be completed at rest on room air
    • an ABG result obtained during an acute exacerbation is not accepted
  • Oximetry testing and its requirements:
    • the oximetry test is performed on room air and on supplemental oxygen to confirm that a client's medical condition improves when supplemental oxygen is administered
    • the test results must include the flow rate, the oxygen saturation, the pulse, the distance walked and the level of shortness of breath (using the Borg Scale)
    • each printout or manually completed form must record at least 5 continuous minutes of monitoring, if client can tolerate. In situations where testing cannot be completed an explanation should be provided
    • the Oximetry Instructions and Form, found on the Express Scripts Canada NIHB provider and client website, has been created as an optional tool for providers
    • note that for Portable oxygen concentrator (POC) requests, the oximetry testing should be completed using the requested item. Testing results must be submitted
    • note that for oxygen conserving device (OCD) requests, oximetry testing should be completed using the requested item. Providers are not required to submit the oximetry testing results using an OCD to support that the client can trigger the device. Oximetry test results must be kept in the client file and submitted if requested for verification purposes. When the client is unable to activate the device, providers are required to inform the regional office to update the prior approval
  • Capillary blood gas (CBG)
    • may be submitted for funding consideration for neonatal and pediatric clients

*Please note: although an ABG assessment is not required, it may be requested to confirm eligibility.

5.2.2 Medical indications

  • adult resting hypoxemia
  • adult exertional hypoxemia
  • adult nocturnal desaturation
  • cardiac conditions
  • palliative care
  • pediatric hypoxemia

5.2.3 Adult resting hypoxemia

Documentation required Testing criteria
(client must meet ONE)
  • prior approval form including items listed in section 5.1.3 Prior approval requirements
  • Arterial blood gas (ABG) or 5-minute oximetry strip at rest on room air as in section 5.2.1 Testing information
  • assessment by RRT/RN/RPN/LPN (if available for initial 3 months, otherwise required for renewal)
  • a PaO2 of 55 mmHg or less
  • a PaO2 between 56 and 59 mmHg with hypoxia on exertion (SpO2 less than 89% for 2 continuous minutes)
  • a PaO2 of 60 mmHg or less with evidence of cor pulmonale, pulmonary hypertension and/or secondary polycythemia

OR

  • oximetry at rest that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)

5.2.4 Adult exertional hypoxemia

Documentation required Testing criteria
(client must meet A, B* & C)
  • prior approval form including items listed in section 5.1.3 Prior approval requirements
  • Arterial blood gas (ABG) or 5-minute oximetry strip at rest as detailed in section 5.2.1 Testing information
  • oximetry on exertion with:
    • Borg Scale
    • distance walked
    • time travelled
  • assessment by RRT/RN/RPN/LPN (if available for initial 3 months, otherwise required for renewal)
  1. Room air testing at rest (oximetry or ABG):
    • SpO2 greater than 90%, OR
    • PaO2 greater than 60 mmHg (for example, demonstrating non-hypoxemia at rest)
  2. Exercise testing on room air:
    • sustained desaturation (SpO2 less than 89% for 2 continuous minutes)
  3. Exercise testing with supplemental oxygen:
    • testing must be performed with the requested equipment
    • improved breathlessness (BORG scale increase of at least one unit at the end of the exercise)
    • improved exercise capacity (improved walking distance by at least 25% and at least 30 meters OR time traveled increased by at least 25% and at least 2 minutes)
*If exercise testing on room air demonstrates a SpO2 less than 80% with good pulse tracking regardless of dyspnea or distance walked, the applicant meets eligibility criteria and no further testing is required for the requested funding period.

5.2.5 Adult nocturnal desaturation

Documentation required Testing criteria
(client must meet A & B)
  1. room air testing demonstrating nocturnal desaturation less than 89% for 30% of the night
  2. sleep-disordered breathing must be ruled out

5.2.6 Cardiac conditions

Documentation required Testing criteria
(client must meet A & B)
  • prior approval form including items listed in section 5.1.3 Prior approval requirements
  • 5-minute oximetry strip at rest on room air only as detailed in section 5.2.1 Testing information
  • documentation provided by a physician to support New York Heart Association Stage IV Heart Disease (only required for initial 3 months)
  • assessment by RRT/RN/RPN/LPN (if available for initial 3 months, otherwise required for renewal)
  1. New York Heart Association Stage IV Heart Disease* (Severe)
  2. oximetry that demonstrates sustained desaturation (SpO2 less than 89% for 2 continuous minutes)
*Defined as: unable to carry-on any physical activity without discomfort. Symptoms of Congestive Heart Failure (CHF) are present at rest (severe CHF). Any activity increases symptoms, or is symptomatic at less than ordinary levels of activity or may or may not be asymptomatic at rest.

5.2.7 Pediatric — for children (18 years of age or less)

Documentation required Testing criteria
(client must meet ONE)
  • oximetry that demonstrates sustained desaturation (SpO2 less than 93%) or nocturnal oxygen desaturation (SpO2 less than 92% for 12% of the night)
  • supplemental oxygen may be considered with a letter from the prescribing physician outlining the evidence for supplemental oxygen if the above criteria have not been met
*special consideration will be given to children who are unable to tolerate room air testing

5.2.8 Palliative care

The client must have been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less.

NIHB's palliative care home oxygen coverage period is for up to six-months of palliative oxygen. Following this six month period, a client will be considered a regular recipient of oxygen coverage, and therefore regular testing requirements will apply.

Documentation required Testing criteria
(Client must meet ONE)
  • PaO2 of 60 mmHG or less

OR

  • oximetry that demonstrates sustained desaturation (SpO2 less than 92% for 2 continuous minutes)
Dyspnea that cannot be improved with medication and/or comfort analgesia must be supported by documentation from physician, nurse practitioner or palliative care team member (for example, Registered Nurse).

5.2.9 Cylinder rental

As part of the monthly rental fees the following should be included:

  • an oxygen cylinder with content
  • a regulator
  • a device that is appropriate for the client's usual mode of mobility that allows safe portability of the cylinder, such as a holder, cart, cylinder bag, or a shoulder pouch with strap

If the oxygen system is rented, the disposables are automatically included in the price of the rental.

5.2.9.1 Gas content only (for cylinders)

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400221 Cylinder D (356 l) content MD, NP, PA OP Yes
99400226 Cylinder E (622 l) content MD, NP, PA OP Yes
99400229 Cylinder S/M (5260 l) content MD, NP, PA OP Yes
99400230 Cylinder H/K (6900 l) content MD, NP, PA OP Yes
99400233 Liquid oxygen (in kg) MD, NP, PA OP Yes

5.2.9.2 Oxygen system with content, regulator, holder, cart, shoulder pouch and straps

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400227 Cylinder D (356 l) system rental MD, NP, PA OP Yes
99400228 Cylinder E (622 l) system rental MD, NP, PA OP Yes
99400231 Cylinder S/M (5260 l) system rental MD, NP, PA OP Yes
99400634 Cylinder H/K (6900 l) rental MD, NP, PA OP Yes
99400544 Oxygen conserving device, rental MD, NP, PA OP Yes Device replaces standard regulator
99400225 Liquid o2 system portable MD, NP, PA OP Yes

5.2.9.3 Oxygen cylinder only (additional)

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400631 Cylinder D (356 l) rental MD, NP, PA OP Yes
99400632 Cylinder E (622 l) rental MD, NP, PA OP Yes
99400633 Cylinder S/M (5260 l) rental MD, NP, PA OP Yes
99400232 Cylinder H/K (6900 l) rental MD, NP, PA OP Yes

5.2.10 Concentrator purchase

If the oxygen system is purchased, the disposables may be billed only if they are not included in the maintenance agreement for oxygen system.

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400473 Concentrator, purchase MD, NP, PA OP Yes 1 every 5 years
99400828 Homefill, purchase MD, NP, PA OP Yes 1 every 5 years
99400862 Portable concentrator +2 batteries, purchase MD, NP, PA OP Yes 1 every 5 years POC includes 2 batteries (one that comes with the purchased device plus one extra interchangeable battery)

5.2.11 Concentrator rental

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400224 Concentrator stationary w/backup cylinder, rental MD, NP, PA OP Yes
99400863 Concentrator portable (POC) + 2 batteries, rental MD, NP, PA OP Yes POC includes 2 batteries (one that comes with the rented device plus one extra interchangeable battery)
99400829 Homefill, rental MD, NP, PA OP Yes
99400635 Dual system without content, rental MD, NP, PA OP Yes
99400636 Dual system with content, rental MD, NP, PA OP Yes

5.3 Supplies

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400220 Concentrator filter MD, NP, PA OP No 12 per year 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
99400235 E-z wrap MD, NP, PA OP Yes 24 per year
99400237 Humidifier (bubble) MD, NP, PA OP No 6 per year
99400238 Oxygen, simple face mask MD, NP, PA OP No 24 per year
99400239 Nasal cannula MD, NP, PA OP No 24 per year
99400207 Oxygen connectors and adaptors MD, NP, PA OP No
99400234 Tubing extension 25 ft. MD, NP, PA OP No 4 per year
99400214 Tubing extension 50 ft. MD, NP, PA OP No 4 per year
99400545 Water traps MD, NP, PA OP No 2 per year
99400864 Concentrator battery replacement OP Yes 2 per year
99400626 Distilled water (4l) MD, NP, PA GEN No 55 per year

5.4 Servicing

5.4.1 Repairs and maintenance

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400638 Maintenance agreement, for purchased oxygen system OP Yes 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
99400243 Oxygen system, repairs OP Yes

5.4.2 Delivery

Item number Item name Prescriber Provider Prior approval required Recommended replacement guidelines Additional details
99400262 Delivery, oxygen OP Yes
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