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1. Pulse oximetry technology is used routinely in clinical care settings to measure arterial oxygen saturation in real time. A pulse oximeter is a machine that attaches to a fingertip, toe, ear, or other site to estimate oxygen levels in the body. The machine uses light energy to “look” at the hemoglobin protein in red blood cells, and find out how much of the hemoglobin proteins have oxygen in them. It is frequently used in emergency rooms, urgent care centers, intensive care units, oxygen clinics, hospitals, and other clinical settings. Health care professionals interpret the data obtained from the device and determine the appropriate treatment for the patient. Like most medical measurement devices, this machine require special evaluation to make sure it is working properly, and not giving false information.
2. A spacer (also known as a chamber, reservoir, Aerochamber®, InspirEase®) is a tube device which attaches to a metered dose inhaler (MDI) for asthma treatment. Some spacers have small masks attached. The asthma medicine is first sprayed into the spacer; then the patient inhales it into the lungs. This drug delivery device helps send more medicine into the lungs in some patients.
3. A peak flow meter is a device that measures breathing capacity and is used by asthmatics or other patients with breathing difficulties:

Indications for Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders are discussed in a separate policy.

Indications for Oxygen Therapy are discussed in a separate policy.

Indications for Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure are discussed in a separate policy.

Indications for the Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asthma and Other Respiratory Disorders are discussed in a separate policy.

Indications for Home Apnea Monitors are discussed in a separate policy.

Indications for the treatment of Sleep Disorders are discussed in a separate policy.

Pulse Oximetry for Home Use is discussed in a separate policy.

• Peak flow meters for patients with respiratory disorders

For coverage criteria of pulse oximetry in the home setting,  refer to the Pulse Oximetry for Home Use medical policy.

When noninvasive ear or pulse oximetry testing is performed in a professional's office, it is considered integral to the professional's medical or surgical care. Therefore, the device is not a distinct or separate service, and separate payment will not be made for the pulse oximeter in these instances.

Computerized peak flow meters (including AirWatch®). Special features such as computerized recording devices are considered convenience enhancements and are not eligible for additional coverage.

None

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

8/1997: Approved by Medical Policy Advisory Committee (MPAC) as Vest Percussor

8/1998: MPAC approved limitation to ThAIRapy® Bronchial Vest/System; policy renamed Oscillatory Devices for Treatment of Cystic Fibrosis

11/1999: Additional respiratory devices approved by MPAC; policy renamed

5/9/2001: Device name change added; ABI VEST® Airway Clearance System (formerly know as ThAIRapy® Vest)

2/7/2002: "The following respiratory devices are not covered" changed to "not medically necessary"

5/2/2002: Type of Service and Place of Service deleted

3/7/2003: Code Reference section updated

7/18/2003: Device name change added: Vest™ Airway Clearance System (formerly known as ABI Vest® Airway Clearance System and ThAIRapy® Vest)

7/2/2004: Oscillary devices added to Policy Guidelines

10/18/2005: Code Reference section updated; HCPCS: E0481 added

9/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy

10/02/2006: Policy updated, all devices not medically necessary

10/5/2006: Coding updated. HCPC codes A7025, A7026, E0481, E0483, E1399 moved to non-covered table. S8185 added to policy

9/24/2009: Description Section revised to include links to Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders Medical Policy, Oxygen Medical Policy, Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure Medical Policy, Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asthma and Other Respiratory Disorders Medical Policy, Home Apnea Monitors Medical Policy, Sleep Disorders Medical Policy, and Aerosolized Antibiotics as a Treatment of Chronic Sinusitis Medical Policy. Information on Cystic fibrosis and oscillatory devices removed. Policy Statement Section revised to remove oscillatory devices information. Coding Section revised to remove ICD9 Diagnosis code 277.0 from Covered Codes Table, and revised to remove HCPCS codes A7025, A7026, E0481, E0483, E0484, S8185 from Non-Covered Codes Table. Verbiage added to Covered Codes Table, "* Some covered procedure codes may have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section". Verbiage added to Non-Covered Codes Table, "*This is not an all inclusive list of non-covered procedure codes."

10/19/2009: Coding Section updated to add HCPCS codes S8096, S8097, S8100, and S8101 to the Covered Codes Table, CPT codes 94760, 94761, and 94762 added to the Non-Covered Codes Table, Added verbiage to HCPCS code E1399 (may use for coding the AirWatch® system) under the Non-Covered Codes Table.

06/21/2011:  Added link to the Pulse Oximetry for Home Use medical policy and deleted the following policy statement: "In a home setting, a health care professional is not available to evaluate and respond to the data obtained from a pulse oximeter. Therefore, the device is considered inappropriate for home use and is not a covered service."

Hayes Medical Technology Directory

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes        

This is not an all-inclusive list of non-covered procedure codes.

All codes billed for this procedure are considered non-covered and not eligible for coverage.

Non-Covered Codes 

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