Continuous Home Pulse Oximetry
DESCRIPTION
Pulse oximetry measures the arterial oxygen saturation of circulating hemoglobin and is considered the standard of care for noninvasively monitoring oxygen levels. Pulse oximetry utilizes selected wavelengths of light to determine the saturation of oxyhemoglobin. The oximeter passes red light through the fingertip or earlobe; the amount of light that is absorbed reflects how much oxygen is in the blood. Changes in the amount of duration of oxygen used can be modified based on the results of pulse oximetry. Inaccurate readings may result from interference from ambient light, highly pigmented skin, low perfusion states, and motion.
Note: This policy exists for the purpose of supporting the Reimbursement Guidelines for Continuous Home Pulse Oximetry.
POLICY
Continuous home pulse oximetry, is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Continuous home pulse oximetry is considered investigational for diagnosing or managing the following conditions/disorders:
Obstructive sleep apnea (adults or children)
Asthma
MEDICAL APPROPRIATENESS
Home pulse oximetry is considered medically appropriate for ANY ONE of the following:
Long-term (years) monitoring of oxygenation needed for ANY ONE of the following:
Diagnosis of a chronic condition that may impair ventilation (e.g., neuromuscular disease such as Duchenne muscular dystrophy or spinal muscular atrophy, airway anomalies such as congenital subglottic stenosis, tracheal malformations, or Pierre Robin, lung disease/disorders of infancy such as bronchopulmonary dysplasia or barotrauma from mechanical ventilation)
Ventilator dependant individual
Short-term (months) monitoring of oxygenation needed for ANY ONE of the following:
Diagnosis of acute respiratory condition with documented oxygen desaturation when the use of home pulse oximetry will guide home oxygen management (e.g., apnea of prematurity, polycythemia, failure to thrive, exacerbations of COPD)
An individual at risk for silent hypoxemia (i.e., status post COVID-19 with severe hypoxemia without dyspnea or other symptoms)
Changes in individual’s condition that requires adjustment of home oxygen therapy (e.g., hypoplastic left heart, post-operative heart surgery such as the Norwood procedure, COPD with resting hypoxemia)
Home supplemental oxygen therapy assessments are needed during ambulation, exercise and/or sleep (e.g., cystic fibrosis, spinal muscular atrophy, use of nighttime home noninvasive ventilation)
Weaning individual from home oxygen therapy
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
There is currently no evidence to support the use of continuous home pulse oximetry for the diagnoses of asthma and obstructive sleep apnea.
SOURCES
American Academy of Sleep Medicine. (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults, 5 (3), 263-276. Retrieved January 6, 2020 from https://aasm.org/clinical-resources/practice-standards/practice-guidelines/.
American Thoracic Society. (2004). Respiratory care of the patient with Duchenne muscular dystrophy. Received January 6, 2020 from https://www.thoracic.org/statements/resources/respiratory-disease-pediatric/duchenne1-10.pdf.
American Thoracic Society. (2019, February). Home oxygen therapy for children. Retrieved January 6, 2020 from https://www.thoracic.org/statements/guideline-implementation-tools/home-oxygen-therapy-for-children.php.
MCG Care Guidelines. (2023). Ambulatory Care 27th Edition. Pulse oximeter (A-0887). Retrieved November 16, 2023 from MCG Health.
ORIGINAL EFFECTIVE DATE: 11/1/2000
MOST RECENT REVIEW DATE: 3/1/2024
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.
This document has been classified as public information.