BlueCross BlueShield of Tennessee Medical Policy Manual

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

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

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. (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.

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.

MCG Care Guidelines. (2020). Ambulatory Care 24th Edition. Pulse oximeter (A-0887). Retrieved October 16, 2020 from MCG Health.

ORIGINAL EFFECTIVE DATE:  11/1/2000

MOST RECENT REVIEW DATE:  10/14/2021

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.