Home Pulse Oximetry
DESCRIPTION
Pulse oximetry measures oxygen saturation levels using a noninvasive probe. Pulse oximetry provides an estimate of arterial oxyhemoglobin saturation (SaO2), using selected wavelengths of light, to determine the saturation of oxyhemoglobin (SpO2).
Pulse oximetry is considered a safe procedure, but has device limitations. False-negative results for hypoxemia and/or false-positive results for normoxemia may lead to inappropriate treatment of an individual. In addition, tissue injury may occur at the site of the probe, as a result of inappropriate use (e.g., pressure sores from prolonged application or electrical shock and burns from the substitution of incompatible probes between instruments).
POLICY
Continuous home pulse oximetry, as adjunctive monitoring, is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Trending home pulse oximetry is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
MEDICAL APPROPRIATENESS
Home pulse oximetry is considered medically appropriate for ANY ONE of the following:
The use of continuous home pulse oximetry is considered medically appropriate if ANY ONE of the following criteria are met:
ALL of the following for adult individuals:
Chronic, progressive condition that requires continuous oxygen therapy
Documented, unpredictable, sub-therapeutic fluctuations of oxygen saturation levels that cannot be clinically determined and would be expected to have an physiological adverse effect if not treated
A trained caregiver is available to respond to changes in oxygen saturation
ABSENCE of ALL of the following:
Routine monitoring for an individual with oxygen
Part of an individual’s asthma management
Note: Generally, these conditions are only seen in ventilator dependent individuals with impaired cognitive responsiveness.
ALL of the following for pediatric individuals:
Diagnosed with a chronic respiratory or cardiovascular disease requiring continuous oxygen supplementation
Oxygen need varies from day to day or per activity (e.g., feeding, sleeping, movement)
Medical need exists to maintain oxygen saturation within a very narrow range
A trained caregiver is available to respond to changes in the oxygen saturation
ABSENCE of ALL of the following:
Routine monitoring for an individual with oxygen
Part of an individual’s asthma management
Note: Generally, these conditions are only seen in premature infants with bronchopulmonary dysplasia (BPD) who are less than 1 year of age.
The use of trending home pulse oximetry is considered medically appropriate if ALL of the following criteria are met:
Medical need exists for recording consistent, predictable variations in oxygen saturation
Used on an infrequent basis and only following major changes in clinical status
Used for brief period of time (e.g., 24 hours)
ADDITIONAL INFORMATION
The use of a trending pulse oximeter is analogous to the use of any other trending device such as a Holter monitor. Therefore, it should only be utilized in specific circumstances and only for short periods of time.
A spot home pulse oximetry check is a single measurement of oxygen saturation that may provide adjunctive information for the clinician. It is no different than any other routine vital sign (e.g., blood pressure) obtained as part of a general individual assessment.
Factors, agents or situations that may affect accuracy of readings and/or performance of the pulse oximetry include:
Motion artifact (e.g., movement)
Abnormal hemoglobin levels, Intravascular dyes
Exposure of probe to ambient light sources during measurement
Low perfusion states (e.g., peripheral vascular disease, low body temperature)
Skin pigmentation (e.g., very dark pigmented African-American individuals)
Nail polish or nail coverings when using finger probe (e.g., acrylic nail overlays)
Inability to detect saturations below 83% with same degree of accuracy and precision seen at higher saturations
Validations of low pulse oximetry derived saturations should be evaluated by arterial blood gas samples in conjunction with full physical assessment of the individual.
Note: "It should be recognized that in individuals receiving supplemental oxygen at high FiO2 and showing a high SpO2 (99%-100%), there can be a dramatic decrease in PaO2 before a corresponding decrease in oxygen saturation is manifested due to the shape of the oxygen-Hb dissociation curve (Sinex, 1999)." In other words, an individual can show high oxygen saturation but really be hypoxic by real oxygen levels in relation to other components of the arterial blood gas evaluation.
SOURCES
110th Congress: 1st Session: H.R:3220 (2009, July). Medicare Home Oxygen Therapy Act of 2009. Retrieved August 18, 2009 from http://thomas.loc.gov .
American Association for Respiratory Care (AARC). (1992, August). AARC Clinical Practice Guideline. Pulse oximetry. Retrieved August 18, 2009 from http://www.rcjournal.com/cpgs/pulsecpg.html.
Balfour, L. (2009). Domiciliary oxygen for children. Pediatric Clinics of North America, 56 (1), 275 - 296. (Level 5 Evidence)
Birnbaum, S., (2009). Pulse Oximetry. Chest, 135 (3), 838 - 841. (Level 5 Evidence)
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2003). Oxygen (1.01.12). Retrieved June 13, 2009 from BlueWeb.
Collop, N. (2009). Portable Monitoring. Sleep Medicine Clinics, 4 (3), 435 - 442. (Level 5 Evidence)
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, April). Home use of oxygen. (NDC 240.2, p. 2-193-196). The Ingenix Complete Guide to Medicare Coverage Issues.
Custer, J., & Rau, R. (Eds.). (2008). Johns Hopkins: The Harriet Lane Handbook (18th ed., pp. 635 - 637). Philadelphia: Elsevier Mosby.
de Wahl -Granelli, A. Wennergren, M., Sandberg, K., Mellander, M., Bejlum,C., Inganas,L., et al. (2009). Impact of pulse oximetry screening on the detection of duct dependent congenital heart disease: a Swedish prospective screening study in 39,821 newborns. British Medical Journal, 338:a3037.doi:10.1136/bmj.a3037. (Level 4 Evidence)
National Guideline Clearinghouse. National Center for Primary Care. (2009 July). Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Retrieved August 18, 2009 from http://www.guideline.gov/summary/summary.aspx?doc_id=5061&nbr=003545&string=copd.
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O’Byrne, P., Bateman, E. D., Bousquet, J., Clark, T., Ohta, K., Paggiaro, P., et al. (2008). Global strategy for asthma management and prevention. Retrieved August 18, 2009 from http://www.ginasthma.com/Guidelineitem.asp?l1=2&l2=1&intId=60.
Strickland, S., Hogan, T., Hogan, R., Sohal, H., McKenzie, W., & Petroski, G. (2009). A randomized Multi-arm repeated - measures prospective study of several modalities of portable oxygen delivery during assessment of functional exercise capacity. Respiratory Care, 54 (3), 344 - 349. (Level 4 Evidence)
Tennessee Code: Title 63 Professions of the Healing Arts: Chapter 31 Polysomnography: Chapter Definitions TENN CODE ANN. § 63-31-101.
U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. LCD for Oxygen and Oxygen Equipment (L11446). Retrieved August 18, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=11446&lcd_version=47&basket=lcd%3A11446%3A47%3AOxygen+and+Oxygen+Equipment%3ADME+MAC%3ACIGNA+Government+Services+%2818003%29%3A.
U. S. Department of Health & Human Services. Centers for Medicare & Medicaid Services. LCD for Non-Invasive Pulse Oximetry for Oxygen Saturation Retrieved August 18, 2009 from http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=14311&lcd_version=10&basket=lcd%3A14311%3A10%3ANon%2DInvasive+Pulse+Oximetry+for+Oxygen+Saturation%3AFI%3AWisconsin+Physicians+Service+Insurance+Corporation+%2852280%29%3A.
U. S. Food and Drub Administration. (2003, October). Center of Devices and Radiological Health. 510(k) Premarket Notification Database. K032947. Retrieved July 16, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf3/K032947.pdf.
U.S. Food and Drug Administration. (2007, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K070371. Retrieved August 18, 2009 from http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=24050.
U.S. Food and Drug Administration. (2008, June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K952327. Retrieved August 18, 2009 from http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K952327.
ORIGINAL EFFECTIVE DATE: 11/1/2000
MOST RECENT REVIEW DATE: 10/8/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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