Selection criteria required for listed CPT/HCPCS codes

Selection criteria and documentation are required to support medical necessity for listed CPT and HCPCS codes. When submitting claims for CPT codes 94760, 94761, 94762 or HCPCS codes E0445 and A4606, include documentation that the member meets one of the medical necessity indications in this policy (for example: chronic lung disease, severe cardiopulmonary disease, neuromuscular disease affecting respiration, ventilator dependence, short-term physician-directed oxygen adjustment, weaning from home oxygen, or interstage monitoring after the Norwood procedure).

• Affected CPT codes (selection criteria required): 94760, 94761, 94762
• Affected HCPCS codes (selection criteria required): E0445, A4606
• Include supporting clinical documentation (diagnoses, oxygen requirements, physician orders, duration, and specific reason for home monitoring)

Prior authorization — not specified

Prior authorization is not specifically required by this Clinical Policy Bulletin excerpt. Providers should follow the member's benefit plan and DME supplier rules for any prior authorization or pre-certification requirements; the CPB itself does not define prior authorization obligations.

• Check the member's plan benefits and DME supplier guidelines for any prior authorization requirements
• This Clinical Policy Bulletin assists in administering plan benefits but does not, by itself, establish prior authorization

Denial risk for investigational indications

Use of home pulse oximetry or capnography for indications listed as experimental/investigational (for example: asthma management, diagnosing nocturnal hypoventilation associated with neuromuscular disorders, evaluating/teaching CPAP, predicting need for adenotonsillectomy when used alone as a screening test, COVID-19 exertional desaturation evaluation, maintenance/continuous monitoring other than ventilator-dependent persons) carries a high risk of coverage denial. Ensure these are not billed as medically necessary without prior medical review.

• Examples of investigational indications with denial risk: asthma self-management, CPAP teaching/evaluation, general screening for OSA when used alone, exertional desaturation in COVID-19 (unless supported by medical review)
• Claims for investigational uses should include documentation of medical review if coverage is being requested

Asthma — evidence gap

There is insufficient evidence to support routine use of home pulse oximetry for asthma self-management without involvement of a qualified healthcare professional. Randomized trial evidence is lacking and patient use without professional guidance is not supported.

• Do not rely on home pulse oximetry alone for asthma action plans; document clinician involvement if oximetry is used in asthma care

Clinical indication documentation

Documentation must demonstrate that the member meets one of the policy's listed medical necessity indications. Include diagnosis codes, clinical findings, physician orders, duration expected (e.g., short-term one month when applicable), oxygen liter flows, reason for monitoring (e.g., ventilator dependence, weaning, interstage monitoring), and any relevant test results.

• Required documentation: clinical diagnosis, physician order, rationale for home monitoring, specific monitoring parameters and alarms, expected duration
• For CCHS, include alarm settings and PETCO2 monitoring plan when applicable

Documentation and responsibility note

Clinical Policy Bulletins are developed to assist in administering plan benefits and do not substitute for the treating provider's responsibility for patient care. Treating providers remain responsible for medical advice and treatment decisions. Coverage determinations are governed by the member's benefit plan.

• Providers remain responsible for clinical management and device selection
• Benefit plan terms govern coverage; CPBs are informational and subject to change

COVID-19 RPM — program documentation

For COVID-19 remote patient monitoring (RPM) programs using exertional desaturation tests, document the chosen exercise test, rationale for its selection (safety and validation considerations), instructions given to the patient, and any monitoring thresholds/triggers for escalation. Evidence for validation of exertional tests in COVID-19 is limited; programs should record the test protocol and safety measures.

• Document which exertional test was used (e.g., 1-minute sit-to-stand, 40-step test), justification for choice, and patient instructions
• Record desaturation thresholds and escalation plan used by the RPM program

Step therapy — not specified

No step therapy requirements are specified in the provided excerpt. Follow the member's plan for any step therapy or conservative-therapy prerequisites.

• If step therapy rules apply under the member's benefit plan, ensure documentation of prior conservative measures per plan rules