BlueCross BlueShield of Tennessee Medical Policy Manual

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 limitation. False-negative results for hypoemia and/or false-positive results for normal oxygen saturation 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).

Note:  This policy exists for the purpose of supporting the Reimbursement Guidelines for Home Pulse Oximetry and the established fees and reviews associated with that reimbursement policy.

POLICY

MEDICAL APPROPRIATENESS 

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)

        • 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.

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 for short periods of time.

A spot home pulse oximetry check is a single measurement of oxygen saturation that may provide adjunctive information of the clinician. It is no different than any other routine vital sign (e.g., blood pressure) obtained as part of a general individual assessment. (Note: spot sat checks should never utilize the HCPCS code E1399.)

Factors, agents or situations that may affect accuracy of readings and/or performance of the pulse oximetry include:

SOURCES

Adde, F. V., Alvarez, A., E., Barbisan, B. N., & Guimaraes, B. R. (2013). Recommendations for long-term home oxygen therapy in children and adolescents. Journal of Pediatrics, 89 (1), 6-17. (Level 2 evidence)

American Academy of Pediatrics. (2014) Clinical practice guideline: the diagnosis, management and prevention of bronchoiolitis. Pediatrics. 2014;134:e1474–e1502.

American Academy of Pediatrics. (2016) Clinical report: apnea of prematurity. Retrieved March 12, 2018 from http://pediatrics.aappublications.org.

American Thoracic Society. (2015). Appropriate candidates for long term oxygen therapy. Retrieved May 18, 2016 from www.thoracic.org.

Nardi, J., Prigent, H., Adala, A., Bohic, M., Lebargy, F., Quera-Salva, M.A. (2012). Nocturnal oximetry and transcutaneous carbon dioxide in home-ventilated neuromuscular patients. Respiratory Care, 57 (9), 1425-1430. (Level 4 evidence)

Pavone, M., Cutrera, R., Verrillo, E., Salerno, T., Soldini, S., & Brouillette, R. T. (2013). Night-to-night consistence of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatric Pulmonology, 48 (8), 754-760. Abstract retrieved May 20, 2016 from PubMed database.

U. S. Food and Drug Administration. (2013, March). Center for Devices and Radiological Health. Pulse Oximeters - Premarket Notification Submissions [510(k)s] Guidance for Industry and Food and Drug Administration. Retrieved March 31, 2017 from www.accessdata.fda.gov

U. S. Food and Drug Administration. (2015, October). Center for Devices and Radiological Health. Pre-market approval decisions for October 2015. Retrieved May 23, 2016 from www.accessdata.fda.gov.

Welsh, E. J., & Carr, R. (2015). Pulse oximeters to self-monitor oxygen saturation levels as part of a personalized asthma action plan for people with asthma. Cochrane Database Systematic Review, 9, CD011584.  Abstract retrieved May 18, 2016 from PubMed database.

ORIGINAL EFFECTIVE DATE:  11/1/2000

MOST RECENT REVIEW DATE:  4/12/2018

ID_Product Development

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.