A pulse oximeter for home use is considered medically necessary durable medical equipment (DME) when one of the following indications is met:
- To determine appropriate home oxygen liter flow for ambulation, exercise, or sleep; or
- To monitor individuals on a ventilator at home; or
- When a change in the member's physical condition requires an adjustment in the liter flow of their home oxygen needs; or
- When weaning the member from home oxygen.
When used for indications other than those listed above including, but not limited to, asthma management or when used alone as a screening/testing technique for suspected obstructive sleep apnea (OSA), a pulse oximeter for home use is considered not medically necessary.
Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.
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.
Coverage for durable medical equipment (DME) is determined according to individual or group customer benefits.
- 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.
- NOTE:
- 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.
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