Medical Policy Bulletin

Section:	Durable Medical Equipment
Number:	E-25
Topic:	Pulse Oximetry Device
Effective Date:	August 1, 2005
Issued Date:	September 10, 2007
Date Last Reviewed:	03/1998

General Policy Guidelines

Indications and Limitations of Coverage

Medically necessary pulse oximeters used in the home are eligible.

The pulse oximeter may also be used in a physician's office during non-invasive ear or pulse oximetry testing to determine oxygen saturation levels. When used in this setting, the device is not eligible for reimbursement. A participating, preferred, or network provider cannot bill the member for the denied service. For information on pulse oximetry testing, see Medical Policy Bulletin V-31, Medical Visits and Associated Services.

NOTE:: Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

The pulse oximeter (E0445) is a device used to measure arterial (blood) oxygen saturation. A small clamp is placed on a patient's finger, toe or earlobe. A light beam from within the clamp is then passed from one side of the clamp to the other. The oximeter then interprets the information gathered and determines the saturation of oxygen in the blood. The data obtained from the device is then interpreted by a health care professional who uses the data to determine appropriate treatment of the patient.

The device, in addition to monitoring the oxygen level of the blood, can be equipped with an alarm which sounds when the oxygen level falls below a certain threshold. This alarm permits immediate definitive action to be performed. The definitive action may be as little as reattaching a dislodged clamp, to administering medical care in response to the condition which caused the oxygen level to fall below the specified threshold.

Procedure Codes

A4606

E0445

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 001 of E-25]

Table Attachment

Text Attachment

Procedure Code Attachment

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.