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DESCRIPTIONPulse oximetry is a method of measuring and monitoring arterial blood oxygenation with the use of an oximeter. A small lightweight device attaches to a finger, toe, or earlobe, and two wavelengths of light are directed through the body tissue. The pulsating arterial blood in the tissue absorbs some of the light, causing small variation in detected light. A detector then measures the absorption and provides a measurement of arterial oxygen saturation. This provides a simple, noninvasive technique for measuring arterial oxygen saturation. Pulse oximetry is used in a variety of settings, including hospitals, clinics, physician offices and homes. Continuous pulse oximetry is used routinely in certain facility settings such as operating rooms, recovery rooms, intensive care units and other settings where detection of hypoxemia is important. In many situations, it has replaced the use of arterial blood gas analysis to diagnose hypoxemia.
Home pulse oximetry is a safe, noninvasive method of measuring oxygen saturation levels. It is a standard of care when used in the management of patients with respiratory disorders who are on long-term oxygen therapy. The medical literature does not indicate 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.
Intermittent or short-term pulse oximetry readings are routinely used in the home for patients on long-term oxygen therapy. It is part of the assessment used in determining the initial need for oxygen therapy. The need for ongoing oxygen should be assessed via pulse oximetry performed by the attending physician or an independent respiratory practitioner three months after initiation of home oxygen. Pulse oximetry is also performed for patients on long-term oxygen therapy when there is a change in their medical condition, to determine the appropriate oxygen settings. For patients on long-term oxygen therapy, an oximetric measurement is performed periodically to determine if the therapeutic goals are being met.
Oxygen therapy and pulse oximetry are often used in the home management of infants and children with chronic lung disease (e.g., bronchopulmonary dysplasia [BPD]). 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 the caretaker 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.
Ambulatory oximetry monitoring has been proposed as a tool for identifying candidates for long-term oxygen therapy for patients with chronic obstructive pulmonary disease (COPD). The standard method of determining oxygen requirements in these patients is based on a standard oximetric measurement. The ATS/European Respiratory Society (ERS) have 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. A prospective cohort study performed with 20 patients with COPD for the purpose of comparing the standard method with ambulatory oximetry monitoring found 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.
POLICYIntermittent or short-term pulse oximetry in the home may be considered medically necessary to gauge the need for supplemental oxygen in individuals with diagnosis of chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving muscles of respiration.
Intermittent or short-term pulse oximetry in the home may be considered medically necessary for the periodic evaluation of oxygen saturation level for individuals on long-term medically necessary oxygen therapy.
Continuous or long-term pulse oximetry in the home may be considered medically necessary to monitor supplemental oxygen use for the following:
Continuous home pulse oximetry is considered investigational when used as screening or diagnostic testing for sleep apnea.
Continuous home pulse oximetry is considered investigational for the monitoring of a stable respiratory condition.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY03/31/2011: Approved by Medical Policy Advisory Committee.
09/01/2015: Code Reference section updated for ICD-10.
SOURCE(S)Cigna Medical Coverage Policy
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.