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Home Pulse Oximetry Device

Section: Durable Medical Equipment
Effective Date: July 01, 2018
Revised Date: May 14, 2018
Last Reviewed: July 16, 2019

Description

The pulse oximeter is a device used to measure arterial (blood) oxygen saturation. A small clamp is placed on a patient’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 patient. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

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) 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 patient 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).

Procedure Codes

E0445

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 patients with tracheostomies; or
  • To monitor premature or infants less than one (1) year of age with bronchopulmonary dysplasia; or
  • The patient 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

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

When the pulse oximeter is used to determine oxygen saturation levels in a physician’s office or as part of any other medical care and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same data of service includes the allowance.

Procedure Codes

E0445 94760 94761

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.

Note: Modifier RA or RB must be indicated when the replacement is a disposable oximeter probe.

Procedure Codes

A4606

Diagnosis Codes

Covered diagnosis for procedure codes: E0445 and A4606

E84.0 E84.9 E84.11 E84.19 E84.8 I73.9 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 P22.0 P22.1 P27.1 P27.8 P27.9
P28.3 Q23.4 R06.81 R09.02 Z99.11 Z99.81

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