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    v1.0.28
    OpenPayerPolicy UpdatesPulmonologyhusky health noninvasive pulse oximeter Prior Auth…
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    Currenthusky_healthPolicy N/A

    Noninvasive pulse oximeter coverage criteria

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    Governs prior authorization, clinical criteria, and documentation requirements for noninvasive pulse oximeters provided to HUSKY Health (Connecticut Medicaid) members; affects enrolled CMAP providers requesting coverage for home monitoring devices.

    Policy Summary
    Payerhusky_health
    PolicyNoninvasive pulse oximeter coverage criteria
    Policy CodePolicy N/A
    Change TypeRevised operational requirements
    Effective DateFeb 1, 2025
    Last ReviewDec 26, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization and submit a completed online authorization request with a signed prescription and treating practitioner documentation dated within the last 3 months.
    SourceLink
    POLICY UPDATE CHANGES

    Prescription and documentation time requirements changed from 12 to 3 months.

    Procedure section clarified that prior authorization, when granted, is for a three-month rental period and subsequent requests are reviewed under the DME Rent to Purchase policy.

    The separate 'Reauthorization' header and section were removed.

    The 'Initial Authorization' header was removed from publication history notes.

    3 monthsauthorization rental period / prescription/documentation recency
    E0445CPT/HCPCS code listed for device

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    4 indications
    listed clinical indications for coverage
    Prior authadministrative requirement

    Coverage Criteria

    Initial Authorization

    A noninvasive pulse oximeter for home monitoring may be considered medically necessary when ANY of the following are met:

    Initial Authorization Indications: A. Chronic respiratory, cardiovascular, or neuromuscular disease affecting the muscles of respiration requiring adjustments in oxygen concentration; B. Tracheostomy and/or ventilator dependent who requires monitoring; C. On oxygen therapy and requires monitoring of oxygen saturation level; D. Infant or child who requires monitoring of oxygen saturation level and heart rate, with or without oxygen, due to conditions such as, but not limited to, congenital heart disease, pulmonary hypertension, or chronic lung disease.

    Any single indication is sufficient for consideration of medical necessity.

    Limitations: Not Applicable.

    No additional coverage criteria are listed beyond the specified initial authorization indications. Coverage is governed by the initial authorization conditions that allow a noninvasive pulse oximeter for home monitoring when any one of the listed clinical indications is met.

    Coding

    Covered HCPCS CodesHCPCSCovered
    E0445Oximeter device for measuring blood oxygen levels, non-invasively

    Provider Actions & Administrative Requirements

    Prior Authorization

    Prior authorization required; 3-month rental authorization

    Prior authorization is required for a noninvasive pulse oximeter. If approved, authorization is granted for a three‑month rental period; subsequent requests are reviewed under the Durable Medical Equipment (DME) Rent to Purchase Policy.

    Note

    Administrative review and DME procedures

    Requests for coverage are reviewed in accordance with procedures for durable medical equipment; coverage determinations are based on submitted case-specific information.

    Documentation Required

    Required documentation for initial requests

    Definitions

    Noninvasive pulse oximeter — definition and placement
    Device descriptionA device that measures oxygen saturation level in blood and can also measure and record heart rate; uses a sensor connected by a wire to a monitor which displays oxygen saturation and heart rate
    Sensor placementSensor is placed on a finger, toe, or ear and uses wavelengths of light to estimate arterial oxygen saturation
    Connection and displayThe sensor is connected by a wire to a monitor that displays both the oxygen saturation level and the heart rate
    Intended settingMay be used in the home setting to monitor individuals with circulatory, respiratory, or other conditions that affect oxygenation
    Medically Necessary / Prior Authorization
    Medically necessary — definition

    Background

    A noninvasive pulse oximeter measures arterial oxygen saturation (SpO2) and heart rate using a sensor placed on a fingertip, toe, or earlobe and is intended for home monitoring of individuals with conditions that affect oxygenation.

    Use of a pulse oximeter in the home setting supports monitoring for patients with chronic respiratory, cardiovascular, or neuromuscular conditions, those who are tracheostomy- or ventilator-dependent, individuals receiving supplemental oxygen, and infants/children requiring oxygen saturation and heart rate surveillance. Device provision is subject to the policy’s clinical indications and prior authorization requirements.

    Policy Summary
    Payerhusky_health
    PolicyNoninvasive pulse oximeter coverage criteria
    Policy CodePolicy N/A
    Change TypeRevised operational requirements
    Effective DateFeb 1, 2025
    Last ReviewDec 26, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization and submit a completed online authorization request with a signed prescription and treating practitioner documentation dated within the last 3 months.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions & Administrative RequirementsDefinitionsBackground

    Submit a fully completed authorization request via the online web portal, a signed prescription dated within the last 3 months from a physician/APRN/PA, treating practitioner documentation written within the past 3 months supporting medical need, and pricing information per the DSS Pricing Policy for MEDS items.

    • Fully completed authorization request via on-line web portal
    • Signed prescription by physician, APRN, or PA dated within the last 3 months
    • Documentation from the treating practitioner written within the past 3 months as outlined in the Clinical Guideline section
    • Pricing information per the DSS Pricing Policy for MEDS Items
    Denial Risk

    Denial triggers for requests

    Failure to obtain prior authorization or to provide the required documentation may result in denial of the request.

    • No prior authorization obtained
    • Missing fully completed online authorization request
    • No signed prescription dated within the last 3 months
    • No treating practitioner documentation dated within the past 3 months
    • Missing pricing information per DSS Pricing Policy for MEDS items
    Health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual’s medical condition consistent with Connecticut General Statutes; must be clinically appropriate, effective, not primarily for convenience, and not more costly than an equivalent alternative
    Prior authorization — definitionA process for approving covered services prior to delivery based on CHNCT’s determination of whether the requested service is medically necessary
    Authorization is time- and coverage-dependentAuthorization is based on medical necessity at the time it is issued and is not a guarantee of payment; payment depends on active coverage, benefits and policies in effect at time of service