Criteria
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 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.
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
