Medicare Advantage

Medical Policy

Title:

Pulse Oximetry Device in the Home Setting

Policy #:

MA05.042a

Policy

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

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.

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 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/web/jadme/policies/dmd-articles/2020/oxygen-and-oxygen-equipment-final-lcd-l33797-and-response-to-comments-rtc-article-published. Accessed February 06, 2025.

Noridian Heathcare Solutions, LLC. Policy Article. (A52514): Oxygen and oxygen equipment. Effective date: 01/01/2017. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52514. Accessed February 06, 2025.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA05.042a:

03/18/2026	This policy has been reissued in accordance with the Company's annual review process.
04/02/2025	This policy has been reviewed and reissued to communicate the Company's continuing position on Pulse Oximetry Devices in the Home Setting.
04/03/2024	This policy has been reviewed and reissued to communicate the Company's continuing position on Pulse Oximetry Devices in the Home Setting.
01/01/2024	Effective 01/01/2024, this policy applies to New Jersey Medicare Advantage (MA) line of business.
03/22/2023	This policy has been reviewed and reissued to communicate the Company's continuing position on Pulse Oximetry Devices in the Home Setting.
04/06/2022	This policy has been reissued in accordance with the Company's annual review process.
05/19/2021	The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulse Oximetry Devices in the Home Setting.
07/15/2020	This policy has been reissued in accordance with the Company's annual review process.
09/25/2019	This policy has been reissued in accordance with the Company's annual review process.
04/25/2018	The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulse Oximeters in the Home Setting.
03/29/2017	The policy has been reviewed and reissued to communicate the Company’s continuing position on Pulse Oximeters in the Home Setting.
08/01/2016	This 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.

Revisions From MA05.042:

06/10/2015	The 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.
01/01/2015	This is a new policy.

Version Effective Date:

1/1/2024

Version Issued Date: