Continuous Home Pulse Oximetry
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.
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)
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)
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.
There is currently no evidence to support the use of continuous home pulse oximetry for the diagnoses of asthma and obstructive sleep apnea.
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.
MOST RECENT REVIEW DATE: 10/14/2021