Description

Oximeters are noninvasive monitors that measure the oxygen saturation of blood. They are often referred to as pulse oximeters because they also measure and record an individual's heart rate. A sensor is placed on a finger, toe or ear and uses light to estimate the oxygen saturation in the arterial blood; the sensor is connected by a wire to a monitor, which then displays both the oxygen saturation (O2 sat) and the heart rate.

Home oximetry may be used to monitor the O2 sat in the blood of individuals with known or suspected heart disease or many other circulatory or lung disorders. It may be used to assist the physician in determining the correct flow of supplemental oxygen, monitor changes in O2 sat during exercise and assist with management of home ventilators. The units used in the home are usually small, portable hand-held devices, though they can be larger, stationary machines.

Home Oximetry Monitoring

Effective Date: 05/25/2023

Revision Date: 05/25/2023

Review Date: 05/25/2023

Policy Number: HUM-0431-017

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

The Loop System is a wristband-type monitor suggested for use in individuals with chronic obstructive pulmonary disease (COPD) to monitor pulse oximetry, respiration and heart rate. The wristband displays information and when it is charging, transmits data to a dedicated server for analysis by a healthcare provider. The data purportedly aids in the detection of signs of deterioration in the wristband wearer. (Refer to Coverage Limitations section)

The Radius PPG is a wireless, continuous portable monitor that may be used in hospital or home settings. When used in the home, oxygen saturation levels are transmitted via mobile app which connects to a hospital portal for monitoring. (Refer to Coverage Limitations section)

The Oxalert Enhanced Pulse Oximeter (EPO) has been proposed for use in post-operative hospital patients and individuals at home who are receiving opioid therapy. It is worn on the wrist and is purported to prevent respiratory arrest and death from opioid overdose by prompting the individual to breathe (via electrical stimulus and audio prompts) if oxygen levels dip below 90 percent. (Refer to Coverage Limitations section)

Telespirometry utilizes a small hand-held device that provides testing for both spirometry and oximetry. The device records the results, which can then be sent via telephone or wirelessly in much the same way that a pacemaker transmits information to the healthcare provider. This has been proposed as a means to monitor lung function, sleep apnea or desaturation occurrences. An example of this type of device includes, but may not be limited to, Spirotel.

For information regarding sleep studies, please refer to Sleep Studies, Adult Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for intermittent home oximetry monitoring when the following criteria are met:

• Diagnosis of chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving muscles of respiration ONLY for the following indications (maximum of 30 days):

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

1. A change in the individual’s physical condition that requires a physician-directed adjustment in the liter flow of their home oxygen needs; OR
2. Periodic evaluation of oxygen saturation level for an individual on long term medically necessary oxygen therapy (usually only necessary once or twice a year, unless they develop an acute illness); OR
3. Weaning the individual from home oxygen; OR
4. Individual 17 years of age and younger with conditions such as congenital heart disease, neurological or respiratory disease (not an all-inclusive list)

Humana members may be eligible under the Plan for telespirometry following an approved lung transplant for up to one year post transplant. This is generally considered integral to the transplant general service agreement.

Coverage Limitations

Humana members may NOT be eligible under the Plan for home oximetry monitoring or telespirometry for any indications other than those listed above including, but may not be limited to, the following:

• Maintenance or continuous monitoring; OR
• To aid in the diagnosis of obstructive sleep apnea

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan utilizing the following home oximetry monitoring devices for any indications:

• Loop System; OR
• Oxalert EPO; OR
• Radius PPG

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Single use or disposable pulse oximetry probes (A4606) are considered integral to the pulse oximeter and are therefore not separately reimbursable.

Additional information about chronic lung disease/chronic obstructive pulmonary disease (COPD), cardiopulmonary disease, obstructive sleep apnea, apnea monitor use for premature infants and use of home oxygen may be found from the following websites:

• American Heart Association
• American Lung Association
• Healthy Children (American Academy of Pediatrics)
• National Library of Medicine

Medical Alternatives

Alternatives to home oximetry monitoring include, but may not be limited to, the following:

• Arterial blood gas measurement at a healthcare provider’s office or by a home health professional
• Polysomnogram (commonly referred to as a sleep study)
• Pulse oximetry performed by a home health professional

Alternatives to telespirometry include, but may not be limited to, the following:

• Spirometry at a healthcare provider’s office or by a home health professional

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.