BlueCross and BlueShield of Montana Medical Policy/Codes
Pulse Oximeter for Home Use
Chapter: Durable Medical Equipment
Current Effective Date: November 26, 2013
Original Effective Date: November 26, 2013
Publish Date: August 26, 2013
Description

Pulse oximetry provides estimates of arterial oxyhemoglobin saturation (SaO2) by utilizing selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin (SpO2).  An oximeter can be used to monitor and manage patients who require ventilator support, and patients with chronic lung disease (e.g. bronchopulmonary dysplasia, chronic obstructive pulmonary disease).   An oximeter is also used by various health care personnel as an assessment tool.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Pulse oximetry may be considered medically necessary in certain specific situations that are commonly associated with oxygen desaturation, as listed below:

  1. Continuous use of home-based oximetry monitoring for adult patients with a chronic progressive condition or disease that requires continuous oxygen therapy with;
    • Documented unpredictable sub-therapeutic fluctuations of oxygen (O2) saturation levels that cannot be clinically determined and would be expected to have a physiological adverse effect if not treated, AND
    • A trained layperson or nonprofessional caregiver available to respond to changes in oxygen saturation.
  2. Continuous home-based pulse oximetry monitoring for pediatric patients diagnosed with a chronic respiratory or cardiovascular disease requiring continuous oxygen supplementation with: 
    • Oxygen need varying from day to day or per activity (e.g., feeding, sleeping, movement); AND
    • Medical need exists to maintain O2 saturation within a narrow range, AND
    • A trained caregiver available to respond to changes in oxygen saturation.
  3. Short-term (e.g. less than 24 hours) pulse oximetry monitoring for any of the following:
    • Initial evaluation to determine the severity of respiratory impairment, OR
    • Evaluation of an acute change in condition, OR
    • Evaluation of exercise tolerance in a patient with respiratory disease, OR
    • Evaluation to establish medical necessity of an oxygen therapeutic regimen. 
  4. Monitoring of potential adverse effects of prescribed medication with known pulmonary toxicity.

Pulse Oximeter monitoring or testing (continuous or short-term) is considered not medically necessary for the following:

  • Obstructive sleep apnea without significant cardiopulmonary co-morbidities including chronic obstructive pulmonary disease (COPD), obesity, hypoventilation, and heart failure;
  • As a means to diagnose congestive heart failure;
  • Management of asthma;
  • Continuous routine monitoring of stable individual receiving oxygen.

NOTE:  Blood gas studies and pulse oximetry readings must be performed under the order of an attending physician by a qualified provider or supplier of laboratory services. The provider of the oxygen services may not perform the laboratory studies or the pulse oximeter readings.

Rationale

Measurement of oxygen saturation levels by oximetry is utilized in the management of patients with respiratory disorders receiving long-term oxygen therapy.   Home pulse oximetry measurement is safe and non-invasive. The scientific literature does not establish that home pulse oximetry is effective for the screening or diagnosis of sleep disorders or necessary for the care of patients with stable respiratory disease.

Infants and Children with Chronic Lung Disease

The American Thoracic Society (ATS), in the Statement on Care of the Child with Chronic Lung Disease of Infancy and Childhood, note that an oximeter in the home has the advantage of providing caretakers with useful information. This can be particularly true during times of illness when the home oximetry reports may help determine whether the supplemental oxygen flow rate or concentration should be increased, or whether the child needs to be further evaluated in the office or emergency room. The ATS statement also notes that oxygen saturation measurements are utilized for this condition during the process of weaning from supplemental oxygen.

Chronic Obstructive Pulmonary Disease (COPD)

Continuous ambulatory oximetry monitoring has been proposed as a tool to identify COPD patients that are candidates for long-term oxygen therapy. The standard method of determining oxygen requirements in these patients is based on a standard oximetric measurement. The ATS/European Respiratory Society (ERS) has noted that arterial blood gas assessment is the preferred method to determine oxygen need because it includes acid-base information. The ATS/ERS statement notes that arterial oxygen saturation as measured by pulse oximetry is adequate for trending.  Fussell, et al. (2003) performed a prospective cohort study with 20 patients with COPD for purpose of comparing the standard method with continuous ambulatory oximetry monitoring.  The authors noted that the study supports the hypothesis that there is a poor relationship between results of conventional methods and results from continuous ambulatory oximetry, but that additional studies are needed to determine if the prescription of oxygen based on continuous ambulatory oximetry can result in a higher percent of time in the desired oxygen saturation range.  Gay (2004) reviewed COPD and sleep and noted that “that there is no universal agreement as to how and when COPD patients should be evaluated for nocturnal hypoxemia, because it is controversial what level of nocturnal hypoxemia merits treatment, who should be treated, and how aggressively to follow it.”

The author notes that while the decision for oxygen therapy is usually made during an office visit, home overnight oximetry before and after selection of nocturnal oxygen flow rates should usually be done for optimal management.

For patients with chronic stable cardiopulmonary problems, oximetric determinations are usually not necessary more frequently than once or twice a year.  More frequent testing may be allowed when there is documentation of an acute exacerbation of chronic pulmonary disease (e.g., acute bronchitis in a patient with COPD) or unstable conditions or acute illnesses with signs indicating or suggesting increased hypoxemia.  In all instances, there must be a request documented in the medical record from a physician for these services.

Use of pulse oximeter in the prehospital environment was shown to provide a cost benefit by reducing the amount of oxygen used.  In 1907 patients, oxygen consumption was reduced by 26% and excessive oxygen therapy was avoided in 55% of patients transported by ambulance.  In addition, 11% of the time, use of pulse oximetry identified suboptimally oxygenated patients.

2009 Update

A search of peer reviewed literature through July 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2013 Update

A search of peer reviewed literature through August 2013 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: 94762, E0445
References
  1. AARC (American Association for Respiratory Care) clinical practice guideline. Pulse oximetry.
  2. Respiratory Care. (1991 December) 36(12):1406-9. Accessed April 26, 2006. Available at URL address: http://www.rcjournal .
  3. Pilling, J., M. Cutaia. Ambulatory oximetry monitoring in patients with severe COPD: a preliminary study. Chest. (1999 August) 116(2):314-21.
  4. Macnab, A.J., Susak, L., et al.  The cost-benefit of pulse-oximeter use in the prehospital environment. Prehospital Disaster Medicine (1999) 14:245-50.
  5. Pulse Oximetry FORUM, Child Health Corporation of America. Best Practices in Pediatric Pulse Oximetry. AARC Times April 2000. Accessed April 26, 2006.  Available at URL address: http://www.aarc.org>.
  6. Kelly, A.M., McAlpine, R., et al. How accurate are pulse oximeters in patients with acute exacerbations of chronic obstructive airways disease? Respiratory Medicine (2001)95:336-40.
  7. Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics (2003 April) 111(4 Pt 1):914-7.
  8. Allen J, Zwerdling R, et al. American Thoracic Society. Statement on the care of the child with chronic lung disease of infancy and childhood. American Journal of Respiratory Critical Care Medicine  (2003 August 1)168(3):356-96.
  9. Fussell, Kevin M., Ayo, Dereje S., et al. Assessing Need for Long-Term Oxygen Therapy:  A Comparison of Conventional Evaluation and Measures of Ambulatory Oximetry Monitoring.  Respiratory Care (2003) 48(2):115–9.
  10. Christopher A. Lewis, and Tam E. Eaton.  Home overnight pulse oximetry in patients with COPD : more than one recording may be needed - clinical investigations  CHEST  (2003 April)   
  11. Balfour-Lynn, I.M., Primhak, R.A., et al. Home oxygen for children: who, how and when? Thorax. (2005 January)  60(1):76-81.
  12. Beresford, M.W., Parry, H., et al. Twelve-month prospective study of oxygen saturation measurements among term and preterm infants. Journal of Perinatology (2005 January) 25(1):30-2.
History
August 2013  New 2013 BCBSMT medical policy.
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Pulse Oximeter for Home Use