Home Pulse Oximetry Device

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: April 06, 2020
Last Reviewed: April 06, 2020

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.

Criteria

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:

  • 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 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 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 B97.2 B97.21 B97.29 E84.0 E84.9 E84.11
E84.19 E84.8 I73.9 J12.81 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 J84.17 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 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 April 6, 2020 Adding COVID-19 diagnosis codes for coverage

Links

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.