Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

 

MP 1.01.29

Continuous Overnight Pulse Oximetry for Home Use


 

 

Medical Policy    

Section
Durable Medical Equipment

Original Policy Date
08/2007

Last Review Status/Date
Added Local Policy/11:2007

Issue
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

 


 

Description

Pulse oximetry is a well-established tool routinely used in many settings of modern medicine to determine a patient's arterial oxygen saturation and heart rate.  The decreasing size of pulse oximeters over recent years has broadened their spectrum of use.  For diagnosis and treatment of sleep-disordered breathing, overnight pulse oximetry helps determined the severity of disease.

 


 

Policy

1.  BCI considers Continuous Overnight Pulse Oximetry for home use medically necessary durable medical equipment (DME) for members with any of the following indications:
  1. When weaning the individual from home oxygen; or
  2. To use as a screening test to determine if a polysomnography is indicated; or
  3. To monitor individuals on a ventilator at home.

2.   BCI considers the use of home pulse oximetry not medically necessary for all other indications, including, but not limited to the following:

  1. Asthma management; or
  2. When a change in the individual's physical condition requires an adjustment in the liter flow of their home oxygen needs; or
  3. To determine appropriate home oxygen liter flow for ambulation, exercise, or sleep; or
  4. Solely to diagnose sleep apnea

 

Policy Guidelines

 

Continuous Overnight Pulse Oximetry in the home is appropriate for Members with significant respiratory instability.  Use of oxygen, does not, of itself, require an oximeter.
Pulse oximetry can be used in conjunction with infant home apnea monitoring.  Home pulse oximetry for indications other than those listed above may be considered medically necessary only through the prior authorization process.

 

Benefit Application

no applicable information


 

Rationale

For patients on long-term oxygen therapy, pulse oximetry arterial saturation (SaO2) measurements are unnecessary except to assess changes in clinical status, or to facilitate changes in the oxygen prescription.  Home pulse oximetry is also indicated when there is a need to monitor the adequacy of SaO2 or the need to quantitate the response of Sa O2 to a therapeutic intervention.

A National Heart, Lung and Blood Institute/World Health Organization Global Asthma Initiative Report concluded that pulse oximetry was not an appropriate method of monitoring patients with asthma.  The report explained that, during asthma exacerbations, the degree of hypoxemia may not accurately reflect the underlying degree of ventilation-perfusion (V-Q) mismatch.  Pulse oximetry alone is not an efficient method of diagnosing patients with suspected obstructive sleep apnea.  The sensitivity and negative predictive value of moderate symptoms.  Therefore, a follow up sleep study would be required to confirm or exclude the diagnosis of obstructive sleep apnea.

Home overnight pulse oximetry (OPO) has been used to evaluate nocturnal desaturation in patients with chronic obstructive pulmonary diseases (COPD), however, Lewis et al (2003) found that nocturnal desaturation in patients with COPD exhibited marked night-to-night variability when measured by home OPO.  A single home OPO recording may be insufficient for accurate assessment of nocturnal desaturation.  Gay (2004) stated that for COPD patients who exhibit more profound daytime hypercapnia, polysomnography is preferred over nocturnal pulse oximetry to rule out other co-existing sleep-related breathing disorders such as obstructive sleep apnea (overlap syndrome) and obesity hypoventilation syndrome.

References:

 

1.  National Heart, Lung and Blood Institute (NHLBI) and World Health Organization (WHO).  Global Strategy for Asthma Management and Prevention NHLBI/WHO Workshop (based on a March 1993 meeting).  Publication Number 95-3659.  Bethesda, MD: National Institutes of Health; January 1995.

2.  Lewis CA, Eaton TE, Fergusson W, et al. Home overnight pulse oximetry in patients with COPD: More than one recording may be needed.  Chest. 2003;123(4):1127-1133.

3.  Gay PC. Chronic obstructive pulmonary disease and sleep.  Respir Care. 2004;49(1):39-51; discussion 51-52.

 

Codes

Number

Description

CPT Codes 94762 Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure)
HCPCS Codes E0445 Oximeter device for measuring blood oxygen levels noninvasively

 


 

 

Policy History

Date

Action

Reason

11/01/2007 Add to Durable Medical Equipment section New policy
06/17/08 Replace policy  removed "To diagnose sleep apnea" from not medically necessary indications