Home Pulse Oximetry
Pulse oximetry measures oxygen saturation levels using a noninvasive probe which provides an estimate of arterial oxyhemoglobin saturation (SaO2), using selected wavelengths of light, to determine the saturation of oxyhemoglobin (SpO2). A home pulse oximeter is considered durable medical equipment and can provide a single SaO2 or a continuous reading (trending) of an individual’s oxygenation.
Pulse oximetry is considered a safe procedure, but has device limitation. Inaccurate readings may result from interference from ambient light, highly pigmented skin, low perfusion states, and motion artifact. 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.
Home pulse oximetry, is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Home pulse oximetry is considered investigational for diagnosing or managing the following conditions/disorders:
Obstructive sleep apnea (adults or children)
Home pulse oximetry is considered medically appropriate for ANY ONE of the following:
Long term (years) oxygenation monitoring using home pulse oximetry 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 dependent individual
Short term (months) oxygenation monitoring using home pulse oximetry may be indicated 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)
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
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, and 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, the express terms of the health plan will govern.
Differing from continuous or trending oximetry a ‘spot’ pulse oximetry check is a single measurement of oxygen saturation to provide adjunctive information for the clinician. It may be included with other routine vital signs (e.g., temperature, pulse, and blood pressure) obtained as part of a general assessment. (Note: spot sat checks should never utilize the HCPCS code E1399.)
Factors or situations that may affect accuracy of readings and/or performance of the pulse oximetry include:
Motion artifact (e.g., movement)
Abnormal hemoglobin levels
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
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, 134:e1474-e1502.
American Academy of Pediatrics. (2016). Clinical report: apnea of prematurity. Retrieved March 12, 2018 from http://pediatrics.aappublications.org.
American Association of Respiratory Care. (2012). AARC clinical practice guideline: transcutaneous monitoring of carbon dioxide and oxygen. Respiratory Care, 57 (11), 1955-1962.
American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. (2011, August) Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update. Retrieved January 23, 2019 from http://annals.org.
American Thoracic Society. (2005, December) Statement on home care for patients with respiratory disorders. Retrieved January 23, 2019 from www.atsjournals.org.
American Thoracic Society. (2015). Appropriate candidates for long term oxygen therapy. Retrieved May 18, 2016 from www.thoracic.org.
CMS.gov: Center for Medicare and Medicaid Services. CGS Administrators, LLC. (20148, August) Oxygen and oxygen equipment (LCD ID: L33797). Retrieved January 22, 2019 from https://www.cms.gov.
Global Initiative for Chronic Obstructive Lung Disease (2018) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2018 report. Retrieved January 23, 2019 from www.goldcopd.org.
Janssens, J., Borel, J., Pepin, J., and Somno, VNI. (2014, February). Nocturnal monitoring of home non-invasive ventilation: contribution of simple tools such as pulse-oximetry, capnography, built-in ventilator software and autonomic markers of sleep fragmentation. Revue des Maladies Respiratoires, 31 (2), 107-18. Abstract retrieved January 23, 2019 from PubMed database.
Marcus, C., Brooks, L., Draper, K., Gozal, D., Halbower, A., Jones, J., et al. (2012, September). Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics, 130 (3), 714-55. Abstract retrieved January 23, 2019 from PubMed database.
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. (2004, March). Center for Devices and Radiological Health. Pre-market Notification Database. K031487. (Avant® 2120). Retrieved January 23, 2019 from www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2015, October). Center for Devices and Radiological Health. Pre-market Notification Database. K150314. (Masimo MightySat Rx). Retrieved May 23, 2016 from www.accessdata.fda.gov.
Walsh, B and Smallwood, C. (2017, June). Pediatric oxygen therapy: a review and update. Respiratory Care, 62 (6), 645-661. (Level 5 evidence - expert opinion)
Welsh, E. J., & Carr, R. (2015, September). 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: 5/31/2019
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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