GUIDELINES
FOR
PRESCRIBERS
for the supply of
HOME MEDICAL OXYGEN THERAPY
______________________________________________________________________________________________
Oxygen Prescriber Guidelines
October 2012
Table of Contents
Table of Contents
1.
Guidelines for Prescribers ____________________________________________________ 1
1.1
Introduction __________________________________________________________________ 1
1.1.1.
1.1.2.
Purpose ___________________________________________________________________________ 1
Reference material __________________________________________________________________ 1
1.2
RAP National Schedule of Equipment ____________________________________________ 1
1.3
Prescribers ___________________________________________________________________ 1
1.3.1
1.3.2
1.3.3
1.3.4
2.
Who are Prescribers and what can they prescribe? __________________________________________
Prescriber / Provider Numbers _________________________________________________________
How Prescribers activate the Service ____________________________________________________
Prescriber and Contractor relationship ___________________________________________________
1
2
2
2
Respiratory Disorders ________________________________________________________ 3
Asthma __________________________________________________________________________________
Terminal Malignancy _______________________________________________________________________
Nocturnal Hypoxaemia ______________________________________________________________________
Hypoxia with exercise (Exertional Hypoxaemia) __________________________________________________
3
3
3
4
3.
Cardiac Disorders ___________________________________________________________ 4
4.
Special Circumstances _______________________________________________________ 4
5.
Remote and Isolated Area Referrals ____________________________________________ 4
6.
For All Beneficiaries _________________________________________________________ 4
6.1
Contra-Indications to Oxygen Prescription ________________________________________ 4
6.2
Review Arrangements _________________________________________________________ 5
6.3
Type of Oxygen Source Prescribed _______________________________________________ 5
6.4
Portable Oxygen ______________________________________________________________ 6
6.5
Oxygen Conserving Devices (OCD) ______________________________________________ 6
6.6
Portable Oxygen Concentrators _________________________________________________ 6
7.
Compliance ________________________________________________________________ 7
8.
Aged Care _________________________________________________________________ 7
Residents of an Aged Care Facility _____________________________________________________________ 7
Respite Care ______________________________________________________________________________ 8
9.
Veterans from Allied Countries ________________________________________________ 8
10.
Application/Prescription Information and Process _______________________________ 8
11.
Delivery Requirements _____________________________________________________ 9
12.
Application form __________________________________________________________ 9
_______________________________________________________________________________________________
Oxygen Prescriber Guidelines
October 2012
1. Guidelines for Prescribers
1.1
1.1.1.
Introduction
Purpose
The purpose of these Guidelines is to define and describe the role of Prescribers in relation to the
supply of Home Medical Oxygen Therapy.
If a veteran, war widow(er) or dependant (Entitled Person) fulfils the following criteria and is
eligible to be treated at Departmental expense, then Home Medical Oxygen Therapy will be
provided through a DVA Contractor for as long as the clinical need for treatment exists. If there is
any doubt regarding eligibility, please telephone the Department on 1300 550 457 (metro) or 1800
550 457 (regional), and speak to the Rehabilitation Appliances Program.
Before Home Medical Oxygen Therapy is considered it is expected that an accurate, current
diagnosis has been established, and any reversible factors in the underlying condition are treated
with maximal therapy. Home Medical Oxygen Therapy will not be supplied for dyspnoea in the
absence of significant hypoxia.
A ready-reference summary of these Guidelines is at Attachment A for your convenience.
1.1.2.
Reference material
DVA Material
Prescribers will need to understand and refer to:

these Guidelines;

the Rehabilitation Appliances Program National Schedule of Equipment (The RAP Schedule).
1.2
RAP National Schedule of Equipment
Access to the current RAP Schedule is available at the DVA website. A direct link to the document
is located at www.dva.gov.au/service_providers/rap/Documents/RAP_Schedule.pdf
The RAP Schedule identifies:

the categories of equipment DVA is able to provide to entitled persons under the RAP;

the type or category of health professionals that can prescribe equipment;

which Prescribers can prescribe a particular item or type of product;
The RAP Schedule may be amended from time to time by the Commonwealth.
1.3
1.3.1
Prescribers
Who are Prescribers and what can they prescribe?
Prescribers are listed in the RAP Schedule. The RAP Schedule and its business rules provide
detailed information on Prescribers and what they can prescribe.
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1
Generally, Prescriber prescription rights are limited to products and equipment that reflect the
Prescribers’ areas of professional expertise.
The Application for Home Medical Oxygen Therapy and/or Respiratory Home Therapy Appliances
form (D0804) must be endorsed by the appropriate prescriber for each indication as listed below:
 Respiratory Physicians;
 Physicians;
 Cardiologists;
 Oncologists; and
 General Practitioners in rural areas, where access to an appropriate specialist is impractical.
1.3.2
Prescriber / Provider Numbers
Provider numbers establish that a Prescriber is a health professional. Provider numbers are issued by
Medicare Australia.
To ensure prescriptions are being made by suitably qualified and recognised health professionals,
DVA requires a provider number to accompany each prescription.
Contractors are required to enter the Prescriber’s provider number alongside each invoice.
Occasionally, Prescribers will not have their own provider number. Where the Prescriber is
employed by a health institution (eg hospital, community health centre) the Prescriber should quote
the institution’s provider number.
DVA will validate the provider number through the RAPTOR (DVA’s invoicing) system.
1.3.3
How Prescribers activate the Service
Prescribers activate the Service by:

assessing entitled persons and determining whether RAP items and equipment are clinically
required; and, if so,

completing a DVA Application for Home Medical Oxygen Therapy and/or Respiratory Home
Therapy Appliances form (D0804).
1.3.4
Prescriber and Contractor relationship
DVA requires the relationship between Prescribers and Contractors to be at arm’s length.
Contractors who employ, contract or provide financial benefit to a Prescriber cannot accept
prescriptions from such a Prescriber.
DVA will not accept financial responsibility for the supply of products or services based on
prescriptions from a Prescriber who has a financial association with a Contractor.
The Contractor is required to disclose to DVA personnel, who are employed, contracted or receive
financial benefit from the Contractor and have prescription rights under the RAP Schedule.
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2
2. Respiratory Disorders
The Entitled Person must possess either a DVA GOLD Card or DVA WHITE Card with a relevant
accepted disability. If there is any doubt regarding eligibility, please telephone the Department on
1300 550 457 (metro) or 1800 550 457 (regional), and speak to the Rehabilitation Appliances
Program.
Oxygen will be provided for Chronic Airways Disease, Pulmonary Fibrosis and other respiratory
disease where the following criteria are met.
The Entitled Person’s arterial blood oxygen tension (PaO2) should be equal to or less than 55
mmHg in the absence of significant complicating factors.
A PaO2 equal to or less than 60 mmHg is acceptable where significant complicating factors such
as chronic anaemia, pulmonary hypertension, or polycythaemia exist. In such cases the oxygen flow
rate that maintains PaO2> 60 mmHg (SaO2> 90%) should be identified where possible.
The Department retains the discretion to decide whether or not a co-existing illness constitutes a
significant factor, on the advice of a Departmental Medical Adviser.
Treatment of the respiratory condition should be optimised, and a stable state achieved where
possible, before blood gases are obtained.
Requests for Home Medical Oxygen Therapy will generally only be considered when the
Department is provided with arterial blood gases measured at rest on room air during a stable
phase of the illness, with the exceptions of the conditions noted below:
Asthma
Entitled Persons with repeated episodes of sudden life-threatening asthma despite compliance with
appropriate maintenance therapy will be approved.
Terminal Malignancy
Entitled Persons with primary or secondary lung cancer, with evidence of hypoxaemia and with a
life expectancy of less than six months will be approved. Prescription in these cases is by
Oncologist or Physician except in remote areas where such services are not reasonably accessible.
Nocturnal Hypoxaemia
Entitled Persons with isolated nocturnal hypoxaemia where it is shown that nocturnal oxygen
saturation is equal to or less than 90 percent for more than 5% of the night based on continuous
overnight SaO2 monitoring during sleep, and secondary effects of chronic hypoxia such as daytime
somnolence, polycythaemia or right heart failure are present.
Where possible, an oxygen flow rate that maintains SaO2 greater than 90% should be identified.
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3
Hypoxia with exercise (Exertional Hypoxaemia)
The Department may meet the costs of providing Home Medical Oxygen Therapy if there is
evidence of exercise induced oxygen desaturation on either a walk or step test to SaO2 < 90% while
breathing room air plus a demonstrable improvement in exercise performance on supplemental
oxygen. The protocol and results that demonstrate this must be provided.
A minimum oxygen flow rate required to achieve improvement should also be established.
3. Cardiac Disorders
The Department will meet the cost of providing Home Medical Oxygen Therapy for beneficiaries
with cardiac disease when the PaO2 at rest is less than 55 mmHg at rest on room air in the absence
of significant complicating factors, or 60 mmHg where significant complicating factors exist (see
above).
In isolated cases of extreme cardiac disability, oxygen may be prescribed without blood gas
measurements in the following circumstances:
i. Severe intractable angina on maximal drug therapy where further surgery is not clinically
appropriates.
ii. Recurrent episodic pulmonary oedema, severe pulmonary hypertension or severe chronic cardiac
failure where no other drug therapy or interventional procedures are possible.
These indications are to be primarily thought of as palliative care.
4. Special Circumstances
Requests for Home Medical Oxygen Therapy outside the above guidelines should be discussed with
the Rehabilitation Appliances Program of the Department on 1300 550 457 (metro) or 1800 550 457
(regional).
5. Remote and Isolated Area Referrals
In remote and isolated areas, Home Medical Oxygen Therapy may be prescribed by a general
practitioner for each of the above diagnostic categories. Where practical, written or oral
endorsement is to be obtained from the relevant specialist for the indication. In such cases, the
endorsing specialist’s name and address must be provided in the completed Application/Prescription
form.
6. For All Beneficiaries
6.1
Contra-Indications to Oxygen Prescription
The following should be considered as contra-indications to oxygen prescription:
i. Dyspnoea in COPD with PaO2 > 60mmHg.
ii. Current smokers.
iii. Patients who have not received adequate therapy of other kinds.
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4
iv. Patients who are not motivated to use oxygen therapy according to prescription.
v. Patients who have cognitive impairment that prevent them from managing their own oxygen
therapy appropriately and safely, or where a carer can not assist.
6.2
Review Arrangements
The Department will continue to meet the cost of Home Medical Oxygen Therapy as long as one or
more of the above criteria are satisfied.
The treating physician shall notify the DVA contracted supplier as soon as Home Medical Oxygen
Therapy is no longer considered to be clinically indicated.
It is recommended that the beneficiary be reviewed by the specialist physician at six months after
the initiation of Home Medical Oxygen Therapy and then at least once every 12 months thereafter.
Whilst the treating clinician may wish to forward a copy of any arterial blood gas results obtained at
such reviews, there is no requirement to perform arterial blood gases on a recurring basis in the
absence of any clinical indication.
The Department reserves the right to institute more formal review to ensure that veterans are
receiving optimal oxygen treatment.
6.3
Type of Oxygen Source Prescribed
In cases where Home Medical Oxygen Therapy is used for more than four hours per day at a flow
rate of more than two litres per minute, an oxygen concentrator will be prescribed. It is considered
inappropriate to use an oxygen cylinder to deliver nebulised therapy, as a nebuliser pump would be
equally effective. Where a nebuliser pump would be effective, the Prescriber should complete an
application form and send it to a DVA contracted supplier for the provision of an appropriate form
of nebuliser.
DVA Contracted suppliers have been informed that the equipment supplied should be the most cost
efficient in relation to need.
The Contractor will compare the Prescriber-nominated equipment configuration and flow rate
settings with the following DVA recommendations:



Entitled Persons requiring oxygen for more than four hours per day at a flow rate of greater than
two litres per minute will be provided with an oxygen concentrator;
Where flow rates of greater than four litres per minute are required, two concentrators will be
considered but prior approval must be sought from DVA. In addition provision should include a
regulation device; and
As a basic guide Entitled Persons mobilising more than three hours three times per week should
be considered for an Oxygen Conserver Device.
Should the Prescriber-nominated equipment configuration differ from the DVA-recommended
configuration, the Contractor will clarify the configuration with the Prescriber. Any changes will
be noted by the Contractor on the Application/Prescription form.
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5
6.4
Portable Oxygen
Portable oxygen may be prescribed where its use is likely to enhance mobility for beneficiaries who
fulfil the relevant criteria described above. In most cases, portable oxygen will be supplied as an
adjunct to either a concentrator or an E-type cylinder. In some cases, portable oxygen may be
provided as an alternative form of therapy, especially when the rate of consumption makes it a costeffective alternative.
Supply of cylinders should be a combination appropriate for the Entitled Person’s mobility
requirements outside the home and a trolley or carry bag suitable for the cylinder/s provided.
With deference to any configuration specified in an Application/Prescription DVA recommends the
following configuration as a basis for supply for a patient on a flow rate of two litres per minute and
on Oxygen greater than four hours per day:
1x Oxygen Concentrator and
3 x 160 litre or nearest equivalent cylinder; or
2 x 460 litre or nearest equivalent;
and, in areas prone to ‘blackout’ or power failure,
1 x 690 litre or nearest equivalent cylinder.
Entitled Persons seeking portable oxygen above their prescribed amount will be referred to their
prescribing physician to seek written confirmation of the changed requirement.
6.5
Oxygen Conserving Devices (OCD)
An OCD may be supplied where it would prolong the use of portable cylinders provided to meet
Entitled Persons mobility requirements outside the home and where its issue would prove cost
effective in reducing the number of portable cylinders required.
6.6
Portable Oxygen Concentrators
A portable oxygen concentrator may be funded by the Department in certain situations. The
Department provides portable oxygen concentrators that deliver a pulse dose only. A portable
oxygen concentrator can only be provided when the entitled person has been tested with the device
to ensure that it is clinically appropriate.
The treating specialist should forward an application for the portable oxygen concentrator to a DVA
contracted supplier on the DVA Application for Home Medical Oxygen Therapy form (D0804).
The treating specialist should advise which type of portable oxygen concentrator is required and
whether they choose to arrange oximetry testing in hospital or via the contracted supplier as an in
home service. A portable oxygen concentrator can be provided by our contracted suppliers to enable
the testing to be conducted in a hospital situation or as an in home service.
The specialist is to organise the hospital testing. To arrange supply for in hospital oximetry, the
specialist should contact a DVA contracted supplier to arrange supply of the appropriate portable
concentrator for a trial.
If in home oximetry testing is required, the specialist is to contact a DVA contracted supplier to
arrange supply of the appropriate portable oxygen concentrator. The contracted supplier will
conduct the oximetry in home and submit a report to the specialist. The specialist should then send
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6
information to the Contractor as to the suitability of the portable oxygen concentrator for the entitled
person’s needs.
Ongoing supply of the equipment can only be approved once the testing has been completed, the test
results have been reviewed and a recommendation provided by the treating specialist that a pulse
dose portable oxygen concentrator is appropriate for the entitled persons requirements.
If the oximetry testing indicates that the portable oxygen concentrator is appropriate for the entitled
person’s condition, the contracted supplier will arrange for ongoing supply of the portable oxygen
concentrator. At this point, the contracted supplier will arrange for collection of the entitled person’s
holdings of portable cylinders in lieu of the portable oxygen concentrator. The entitled person will
retain the portable oxygen concentrator, backup cylinder and stationary concentrator.
Where the oximetry testing indicates that the portable oxygen concentrator is not appropriate for the
entitled person’s condition, the contracted supplier should be advised to arrange collection of the
device.
7. Compliance
Some measure of compliance (actual oxygen usage) will be obtained at the time of review.
Inappropriate usage, either too little or too much, will be drawn to the attention of the prescribing
physician. In such cases, the physician may wish to discuss the matter with the Rehabilitation
Appliances Program - telephone 1300 550 457 (metro) or
1800 550 457 (regional).
8. Aged Care
Residents of an Aged Care Facility
DVA is not responsible for the supply of ongoing oxygen treatment in respect of Entitled Persons
receiving low level or high level care in a Commonwealth funded Residential Aged Care Facility
(RACF). Under the Aged Care Act 1997 the Commonwealth provides funding to RACF’s for the
provision of ongoing oxygen treatment to residents who require oxygen on an ongoing basis rather
than for episodic or short-term illnesses, such as bronchitis. The funding is available to care
recipients with a medically identified need.
Residents including Entitled Persons receiving ongoing oxygen treatment who wish to leave the
RACF for short periods of time e.g. social outings and weekend visits, can be provided with some
cylinder oxygen by the RACF.
All RACFs can apply to the Department of Health and Aging for a supplement for residents in need
of and receiving oxygen treatment on an ongoing basis.. This includes residents receiving respite
care and is irrespective of the classification level of the resident.
When an entitled person is placed in a Government funded RACF (regardless of whether low level
care, high level care, or respite), the contracted supplier should be contacted and advised to collect
the DVA funded equipment from the entitled person’s private residence.
The RACF should take over the supply of the oxygen and submit a claim for the supplemental
oxygen funding through the Department of Health and Aging.
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7
Respite Care
DVA is not responsible for the supply of ongoing oxygen treatment in respect of Entitled Persons
receiving respite care in a Commonwealth funded Residential Aged Care Facility (RACF).
All RACFs can apply to the Department of Health and Aging for a supplement for residents in need
of and receiving oxygen treatment on an ongoing basis. This includes residents receiving respite and
is irrespective of the classification level of the resident.
(Reference: Department of Health & Aging – The Residential Care Manual 2009, Edition 1, B.
Funcing and Income for Care Services – Oxygen supplement. These arrangements operate under the
Aged Care Act 1997 and the Aged Care (Consequential Provisions) Act 1997).
9. Veterans from Allied Countries
Applications/Prescriptions for WHITE Card Beneficiaries with DVA File number denoting that the
holder is a veteran of a Country other than Australia should be referred to DVA.
10.
Application/Prescription Information and Process
DVA Contracted Suppliers will only be paid for supply that takes place on the basis of
Applications/Prescriptions completed by authorised prescribers.
Applications/Prescriptions should be made by completing the DVA RAP Application for Home
Medical Oxygen Therapy and/or Respiratory Home Therapy Appliances form (D0804) (see
Attachment 2). This form is designed to capture information necessary for the Contractor to:


Supply product and equipment; and
Provide DVA with a valid invoice.
Applications/Prescriptions not on the form can be accepted only if they are in writing and display:




Application/Prescription
Prescriber’s provider number;
Prescribers’ profession;
Entitled Person’s eligibility;
(Invoices for goods supplied to ineligible persons will not be paid by DVA. The Gold Card indicator
establishes eligibility. White Card indicator should be referred to DVA.)








DVA file number;
Details of Entitled Person including surname, first initial and their gender;
Entitled Person’s postcode if different from delivery address;
Address for items to be delivered including postcode;
Contracted Equipment catalogue number;
Quantity of items supplied;
Prior Approval items;
Date Application/Prescription was signed.
Where the above details are not supplied on the Application/Prescription form, and they cannot be
supplied by Contracted Suppliers, the Contracted Supplier will seek this information from
Prescribers.
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8
Once Contracted Suppliers have verified that the above information is contained in the
Application/Prescription they will compare the Application/Prescription with the criteria set out
above and either progress supply or refer the case to the Department.
11.
Delivery Requirements
DVA has set target delivery times for suppliers. Specified delivery times (from time of receipt of
prescription) are as follows:
4 hours
24 hours
48 hours
for ‘emergency’ orders
for metropolitan, regional and rural areas
for remote areas
(Note: An order shall be deemed to be an ‘emergency’ only where the Prescriber so states and
where it appears appropriate in the circumstances, for example: palliative care, the Entitled Person's
health is at risk; or to enable the Entitled Person's discharge from a public or private hospital).
The Contractor is required to work in conjunction with health professionals and Entitled Persons to
ensure that the Entitled Person has timely access to equipment upon discharge from hospital.
The Contractor will confer, where requested, with prescribers about the request status of emergency
Applications/Prescriptions.
12.
Application form
The DVA Application for Home Medical Oxygen Therapy and/or Respiratory Home Therapy
Appliances form is available on the DVA website:
www.dva.gov.au/dvaforms/Documents/D0804.pdf
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9
Attachment A
DOMICILIARY OXYGEN THERAPY GUIDELINES SUMMARY SHEET
INDICATIONS
RESPIRATORY DISORDERS
1. 1. PaO2 = 55 mmHg or less
Arterial Blood gases must be taken on room air at rest, whilst on optimal treatment. (ie not during acute exacerbations
or while clinically unstable)
OR
2. PaO2 56 - 59 mmHg
With evidence of significant complicating co-morbid conditions such as right heart failure, pulmonary hypertension,
chronic anaemia or polycythaemia. Department retains discretion to decide whether or not co-existing factors constitute
a significant factor.
Where possible identify the O2 flowrate which maintains PaO2 > 60 mmHg (SaO2 > 90%).
EXERTIONAL HYPOXAEMIA
Evidence of exercise induced oxygen desaturation on either a walk or step test to SaO2 < 90% while breathing room air.
PLUS a demonstrable improvement in exercise performance on supplemental O2.
Please note the minimum O2 flowrate required to achieve this improvement.
NOCTURNAL HYPOXAEMIA
Evidence of oxygen desaturation (SaO2 consistently < 90%) based on continuous overnight SaO2 monitoring during
sleep, and secondary effects of hypoxia are present. Identify the O2 flowrate, which maintains SaO2 > 90%.
ASTHMA
Entitled persons with repeated episodes of sudden, life threatening asthma despite compliance with appropriate
maintenance therapy.
TERMINAL MALIGNANCY
Indicated for patients with primary or secondary lung cancer, with evidence of hypoxaemia and with a life expectancy of
less than six months, unless blood gases meet above guidelines. Prescription by Oncologist or Physician except in
remote areas where services of either are not reasonably accessible.
CARDIAC DISORDERS
To be prescribed by cardiologist. Where no cardiologist is available, a specialist physician may prescribe oxygen. In
remote locations an endorsement from a specialist needs to be obtained and noted on referral form. Oxygen to be
prescribed according to the respiratory disorder guidelines noted above.
Oxygen may be prescribed without blood gas measurements in the following circumstances:
 Severe intractable angina on maximal drug therapy where nothing further can be offered surgically.
 Recurrent episodic pulmonary oedema, severe pulmonary hypertension or severe chronic cardiac failure where no
other drug therapy or interventional procedures are possible.
These indications are to be primarily thought of as palliative care.
CONTRA-INDICATIONS TO OXYGEN PRESCRIPTION
1. Dyspnoea in COPD with PaO2 > 60mmHg.
2. Current tobacco smokers.
3. Patients who have not received adequate therapy of other kinds.
4. Patients who are not motivated to use oxygen therapy according to prescription.
5. Patients who have cognitive impairment that prevent them from managing their own oxygen therapy appropriately
and safely, or where a carer can not assist.
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10
Qualifying Data and Measurements Made
RESPIRATORY DISORDERS
Arterial Blood Gases at rest on room air (while on optimised treatment during stable phase of illness)
Date:
/
/
pH:
PaCO2 (mmHg):
PaO2 (mmHg):
SaO2 (%):
Nocturnal SaO2 Assessment
Date:
/
/
Minimal nocturnal SO2%
Exercise Oxygen Assessment
Patients are exercised (step or timed walk) until reaching oxygen desaturation of 90%.
Exercise is then repeated with oxygen with a goal of exceeding the number of steps or distance
walked and keeping saturation above 90%.
Measurements include SaO2%, distance or steps walked and time of exercise.
EXERTIONAL OXYGEN ASSESSMENT – WALK / STEP TEST
Date:
/ /
Room Air only
Using Supplementary
Oxygen
Oxygen Flow (L/min)
Rest (SaO2%)
End Exercise(SaO2%)
Distance (m)/ Steps
completed
Exercise Duration
(mins)
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11