CMS Oximetry Services Form

Summary Of Evidence

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Analysis of Evidence

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Notice: Compliance with the provisions in this policy may be monitored and addressed through post-payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Oximetry measures oxygen saturation using a non-invasive probe. This is done by measuring light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Covered Indications

Medically necessary reasons for pulse oximetry include:

1. Patient exhibits signs or symptoms of acute respiratory dysfunction such as:

• Tachypnea
• Dyspnea
• Cyanosis
• Respiratory distress
• Confusion
• Hypoxia

2. Patient has chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons:

• Initial evaluation to determine the severity of respiratory impairment
• Evaluation of an acute change in condition
• Evaluation of exercise tolerance in a patient with respiratory disease
• Evaluation to establish medical necessity of oxygen therapeutic regimen
• Patient has sustained severe multiple trauma or complains of acute severe chest pain
• Patient is under treatment with a medication with known pulmonary toxicity, and oximetry is medically necessary to monitor for potential adverse effects of therapy

3. Overnight Oximetry is considered medically necessary when performed for any of the following circumstances:
   
   
• The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations
• The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen

Limitations

The following are considered not reasonable and necessary:

1. Routine use of oximetry
2. Results of tests performed by a durable medical equipment supplier to qualify patients for home oxygen service

Place of Services (POS)

These services may be performed in the home or office by a provider or by an independent diagnostic testing facility.

For additional information on services performed in an Independent Diagnostic Testing Facility (IDTF), please refer to Local Coverage Determination (LCD) L35448 Independent Diagnostic Testing Facility (IDTF) and Local Coverage Article: Billing and Coding: Independent Diagnostic Testing Facility (IDTF) A53252.

LCD Individual Consideration

Additional payment may be allowed for oximetric determinations exceeding the parameters described in the “Utilization Guidelines” section below on an “individual consideration” basis.

For frequency limitations please refer to the Utilization Guidelines section below.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.