Pulse Oximeter for Home Use
Durable Medical Equipment
© Blue Cross and Blue Shield of Montana
Current Effective Date:
November 26, 2013
Original Effective Date:
November 26, 2013
August 26, 2013
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.
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.
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.
- AARC (American Association for Respiratory Care) clinical practice guideline. Pulse oximetry.
- Respiratory Care. (1991 December) 36(12):1406-9. Accessed April 26, 2006. Available at URL address: http://www.rcjournal .
- Pilling, J., M. Cutaia. Ambulatory oximetry monitoring in patients with severe COPD: a preliminary study. Chest. (1999 August) 116(2):314-21.
- 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.
- 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>.
- 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.
- 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.
- 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.
- 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.
- 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)
- Balfour-Lynn, I.M., Primhak, R.A., et al. Home oxygen for children: who, how and when? Thorax. (2005 January) 60(1):76-81.
- 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.
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