HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
E-25-024
Topic:
Home Pulse Oximetry Device
Section:
Durable Medical Equipment
Effective Date:
December 31, 2020
Issued Date:
April 19, 2021
Last Revision Date:
April 2021
Annual Review:
March 2021
 
 

The pulse oximeter is a device used to measure arterial (blood) oxygen saturation. A small clamp is placed on a patient's finger, toe or earlobe. The oximeter 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.

Policy Position

Intermittent pulse oximeter monitoring (less than 24 hours) for home use may be considered medically necessary durable medical equipment (DME), from a DME supplier, for ANY ONE of the following indications:

  • To evaluate initial and ongoing medical necessity of an oxygen therapeutic regimen; or
  • To evaluate appropriate home oxygen liter flow for ambulation, exercise, or sleep in a patient with respiratory disease; or
  • To evaluate an acute change in condition requiring an adjustment to the liter flow of home oxygen; or
  • Intermittently as a spot check (digital pulse oximeter).

E0445

 

 

 

 

 

 


Continuous pulse oximeter monitoring for home use may be considered medically necessary DME from a DME supplier, for ANY ONE of the following indications

  • To monitor individuals on  home mechanical ventilation when the ventilator does not have a built in pulse oximeter; or
  • To monitor home care patients with tracheostomies; or
  • To monitor premature or infants less than one (1) year of age with bronchopulmonary dysplasia; or
  • The patient would otherwise require hospitalization solely for the purpose of continuous monitoring; and
  • A trained caregiver is available to respond to changes in the oxygen saturation.

E0445

 

 

 

 

 

 


A pulse oximeter for home use (intermittent or continuous) is considered not medically necessary 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).

E0445

 

 

 

 

 

 


When the pulse oximeter is used to determine oxygen saturation levels in a physician's office or as part of any other medical care and the charges are itemized, combine the charges and pay only the medical care. Payment for the medical care performed on the same data of service includes the allowance.

E0445

94760

94761

 

 

 

 


The replacement of two (2) reusable probes every 12 months or five (5) disposable oximeter probes every one (1) month may be considered medically necessary when the probe is inoperable due to:

  • Faulty or damaged wiring, sensors, pads, connectors, straps; or
  • Damaged or missing springs; or
  • Broken or missing shells; or
  • Inaccurate data evidenced by environmental factors (e.g., movement or body temperature).

Quantity level limits or quantities of supplies that exceed the frequency guidelines listed in the policy will be denied as not medically necessary.

Note: Modifier RA or RB must be indicated when the replacement is a disposable oximeter probe.

A4606

 

 

 

 

 

 


Related Policies

Refer to Highmark Reimbursement Policy RP-041, Services Not Separately Reimbursed, for additional information.  


Covered diagnosis for procedure codes: E0445 and A4606

B34.2

B97.21

B97.29

E84.0

E84.9

E84.11

E84.19

E84.8

I73.9

J12.81

J12.82

J12.89

J20.8

J22

J40

J43.0

J43.1

J43.2

J43.8

J43.9

J44.9

J47.1

J47.9

J80

J84.10

J84.170

J84.178

J84.89

J95.1

J95.2

J95.3

J95.821

J95.822

J96.00

J96.01

J96.02

J96.10

J96.11

J96.12

J96.20

J96.21

J96.22

J96.90

J96.91

J96.92

J98.4

J98.6

J98.8

P22.0

P22.1

P27.1

P27.8

P27.9

P28.3

Q23.4

R06.81

R09.02

U07.1

Z99.11

Z99.81

 

 

 

 

 

 

 

 

 

 


Place of Service: Outpatient

The use of a Home Pulse Oximetry Device is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


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

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.