Home Pulse Oximetry Device

Policy ID: E-25-026

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: May 14, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

The pulse oximeter is a device used to measure arterial (blood) oxygen saturation. A small clamp is placed on an individual's finger, toe, or earlobe. The oximeter interprets the information gathered and determines the saturation of oxygen in the blood. The data obtained from the device is then interpreted by a health care professional who uses the data to determine appropriate treatment of the individual.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Intermittent pulse oximeter monitoring (less than 24 hours) for home use may be considered medically necessary durable medical equipment (DME), from a DME supplier, for ANY ONE of the following indications:

To evaluate initial and ongoing medical necessity of an oxygen therapeutic regimen; or
To evaluate appropriate home oxygen liter flow for ambulation, exercise, or sleep in an individual with respiratory disease; or
To evaluate an acute change in condition requiring an adjustment to the liter flow of home oxygen; or
Intermittently as a spot check (digital pulse oximeter).

Continuous pulse oximeter monitoring for home use may be considered medically necessary DME from a DME supplier, for ANY ONE of the following indications:

To monitor individuals on home mechanical ventilation when the ventilator does not have a built-in pulse oximeter; or
To monitor home care individuals with tracheostomies; or
To monitor premature or infants less than one (1) year of age with bronchopulmonary dysplasia; or
The individual would otherwise require hospitalization solely for the purpose of continuous monitoring; and
A trained caregiver is available to respond to changes in the oxygen saturation.

A pulse oximeter for home use (intermittent or continuous) is considered not medically necessary when used for indications other than those listed above including, but not limited to, asthma management or when used alone as a screening/testing technique for suspected obstructive sleep apnea (OSA).

Procedure Code

E0445

The replacement of two (2) reusable probes every 12 months or five (5) disposable oximeter probes every one (1) month may be considered medically necessary when the probe is inoperable due to:

Faulty or damaged wiring, sensors, pads, connectors, straps; or
Damaged or missing springs; or
Broken or missing shells; or
Inaccurate data evidenced by environmental factors (e.g., movement or body temperature).

Quantity level limits or quantities of supplies that exceed the frequency guidelines listed in the policy will be denied as not medically necessary.

Procedure Code

A4606

Diagnosis Codes

Covered Diagnosis for Procedure Codes: E0445 and A4606

B34.2

B97.21

B97.29

E84.0

E84.9

E84.11

E84.19

E84.8

I73.9

J12.81

J12.82

J12.89

J20.8

J22

J40

J43.0

J43.1

J43.2

J43.8

J43.9

J44.9

J47.1

J47.9

J80

J84.10

J84.170

J84.178

J84.89

J95.1

J95.2

J95.3

J95.821

J95.822

J96.00

J96.01

J96.02

J96.10

J96.11

J96.12

J96.20

J96.21

J96.22

J96.90

J96.91

J96.92

J98.4

J98.6

J98.8

P22.0

P22.1

P27.1

P27.8

P27.9

P28.30

P28.32

P28.33

P28.39

Q20.2

Q23.4

R06.81

R09.02

U07.1

Z99.11

Z99.81

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 4-6-2020 Revision

Added COVID-19 Diagnosis Codes for coverage

Internal Medical Policy Committee 9-21-2020: Coding update -

Removed Diagnosis Code J84.17; and
Added Diagnosis Codes J84.170 and J84.178

Internal Medical Policy Committee 1-19-2021 Coding update

Added Diagnosis Code J12.82

Internal Medical Policy Committee 5-20-2021 Annual Review- updated language

Internal Medical Policy Committee 5-24-2022 Coding update -

Added Diagnosis Code Q20.2

Internal Medical Policy Committee 5-23-2023 -Annual Review - no changes in criteria

Internal Medical Policy Committee 5-14-2024 -Annual Review - no changes in criteria

Added Policy Application

Internal Medical Policy Committee 5-13-2025- Coding update effective July 07, 2025

Added coverage statement under criteria; and
Added Diagnosis Codes P28.30; P28.32; P28.33; and P28.39; and
Removed diagnosis code P28.3.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-25-025

Section: Durable Medical Equipment

Effective Date: July 01, 2018

Revised Date: April 14, 2022

Revision Effective Date: July 01, 2024

Last Reviewed: May 14, 2024

Archived Date: July 06, 2025

Applies To: Commercial and Medicaid Expansion

Description

The pulse oximeter is a device used to measure arterial (blood) oxygen saturation. A small clamp is placed on a individual's finger, toe or earlobe. The oximeter interprets the information gathered and determines the saturation of oxygen in the blood. The data obtained from the device is then interpreted by a health care professional who uses the data to determine appropriate treatment of the individual.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Criteria

To evaluate initial and ongoing medical necessity of an oxygen therapeutic regimen; or
To evaluate appropriate home oxygen liter flow for ambulation, exercise, or sleep in a individual with respiratory disease; or
To evaluate an acute change in condition requiring an adjustment to the liter flow of home oxygen; or
Intermittently as a spot check (digital pulse oximeter).

Continuous pulse oximeter monitoring for home use may be considered medically necessary DME from a DME supplier, for ANY ONE of the following indications

To monitor individuals on home mechanical ventilation when the ventilator does not have a built in pulse oximeter; or
To monitor home care individuals with tracheostomies; or
To monitor premature or infants less than one (1) year of age with bronchopulmonary dysplasia; or
The individual would otherwise require hospitalization solely for the purpose of continuous monitoring; and
A trained caregiver is available to respond to changes in the oxygen saturation.

Procedure Codes

E0445

The replacement of two (2) reusable probes every 12 months or five (5) disposable oximeter probes every one (1) month may be considered medically necessary when the probe is inoperable due to:

Faulty or damaged wiring, sensors, pads, connectors, straps; or
Damaged or missing springs; or
Broken or missing shells; or
Inaccurate data evidenced by environmental factors (e.g., movement or body temperature).

Quantity level limits or quantities of supplies that exceed the frequency guidelines listed in the policy will be denied as not medically necessary.

Procedure Codes

A4606

Diagnosis Codes

Covered diagnosis for procedure codes: E0445 and A4606

B34.2

B97.21

B97.29

E84.0

E84.9

E84.11

E84.19

E84.8

I73.9

J12.81

J12.82

J12.89

J20.8

J22

J40

J43.0

J43.1

J43.2

J43.8

J43.9

J44.9

J47.1

J47.9

J80

J84.10

J84.170

J84.178

J84.89

J95.1

J95.2

J95.3

J95.821

J95.822

J96.00

J96.01

J96.02

J96.10

J96.11

J96.12

J96.20

J96.21

J96.22

J96.90

J96.91

J96.92

J98.4

J98.6

J98.8

P22.0

P22.1

P27.1

P27.8

P27.9

P28.3

Q20.2

Q23.4

R06.81

R09.02

U07.1

Z99.11

Z99.81

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 4-6-2020: Added COVID-19 diagnosis codes for coverage

Internal Medical Policy Committee 9-21-2020: Coding update -

Removed diagnosis code J84.17; and
Added diagnosis codes J84.170 and J84.178

Internal Medical Policy Committee 1-19-2021 Coding update

Added diagnosis code J12.82

Internal Medical Policy Committee 5-20-2021 Annual Review- updated language

Internal Medical Policy Committee 5-24-2022 Coding update -

Added diagnosis code Q20.2

Internal Medical Policy Committee 5-23-2023 -Annual Review - no changes in criteria

Internal Medical Policy Committee 5-14-2024 -Annual Review - no changes in criteria

Added Policy Application

Links

References

Disclaimer

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search

Home Pulse Oximetry Device

Description

Policy Application

Criteria

Procedure Code

Procedure Code

Diagnosis Codes

Covered Diagnosis for Procedure Codes: E0445 and A4606

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Codes

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer