Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Pulse Oximeters in the Home Setting
Policy #:MA05.042a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Pulse oximeters (E0445) and replacement probes (A4606) in the home setting are not covered by the Company, because these items are not covered by Medicare. Therefore, these items are not eligible for reimbursement consideration.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

BENEFIT APPLICATION

Subject to the applicable Evidence of Coverage, pulse oximeters and replacement probes in the home setting and replacement probes are not eligible for payment under the medical benefits of the Company’s Medicare Advantage products because the service is considered not covered.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

There are numerous devices approved by the FDA for pulse oximetry.

Description

A pulse oximetry device indirectly measures the arterial oxygen saturation levels in the blood by using a noninvasive sensor probe on the ear or finger.
References

Noridian Heathcare Solutions, LLC., Local Coverage Determination (LCD). L33797: Oxygen and oxygen equipment. Effective date: 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Oxygen+and+Oxygen+Equipment+LCD+and+PA/7f6a39d8-0342-4478-b1f5-1dd4839ef366. Accessed April 12, 2018.

Noridian Heathcare Solutions, LLC,. Policy Article.(A52514): Oxygen and oxygen equipment. Effective date: 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Oxygen+and+Oxygen+Equipment+LCD+and+PA/7f6a39d8-0342-4478-b1f5-1dd4839ef366 Accessed April 12, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



A4606 Oxygen probe for use with oximeter device, replacement

E0445 Oximeter device for measuring blood oxygen levels noninvasively



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.042a
09/25/2019This policy has been reissued in accordance with the Company's annual review process.
04/25/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulse Oximeters in the Home Setting.
03/29/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulse Oximeters in the Home Setting.
08/01/2016This version of the policy will become effective 08/01/2016.

The Company’s coverage position, in accordance with Medicare has changed from Medically Necessary to Not Covered.


MA05.042
06/10/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on A pulse oximetry device in the home setting.

Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.
01/01/2015This is a new policy.





Version Effective Date: 05/07/2018
Version Issued Date: 08/01/2016
Version Reissued Date: 09/25/2019