Pulse Oximetry for Home Use

POLICY NUMBER

L.1.01.405

DESCRIPTION

Pulse 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.

POLICY

Intermittent 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:

• individuals who require mechanical ventilation

• infants with chronic lung disease (e.g., bronchopulmonary dysplasia)

• premature infants on active therapy for apnea

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 EXCEPTIONS

None

POLICY GUIDELINES

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

03/31/2011: Approved by Medical Policy Advisory Committee.

09/01/2015: Code Reference section updated for ICD-10.

05/31/2016: Policy number L.1.01.405 added. Policy Guidelines updated to add medically necessary and investigative definitions.

09/30/2022: Code Reference section updated to add new ICD-10 diagnosis codes P28.30, P28.31, P28.32, P28.33, and P28.39, effective 10/01/2022.

01/18/2023: Policy reviewed; no changes.

02/15/2024: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis code P28.3.

03/13/2025: Policy reviewed; no changes.

SOURCE(S)

1. Cigna Medical Coverage Policy

2. www.encoderpro.com

CODE REFERENCE

This 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.

Covered Codes

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