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.
Intermittent pulse oximeter monitoring (less than 24 hours) for home use may be considered medically necessary durable medical equipment (DME) for ANY ONE of the following indications:
Continuous pulse oximeter monitoring for home use may be considered medically necessary DME for ANY ONE of the following indications
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).
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:
Quantity level limits or quantities of supplies that exceed the frequency guidelines listed in the policy will be denied as not medically necessary.
Covered diagnosis for procedure codes: E0445 and A4606
Internal Medical Policy Committee April 6, 2020 Adding COVID-19 diagnosis codes for coverage
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.