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    v1.0.28
    OpenPayerPolicy UpdatesDurable Medical Equipment (DME)northwood home pulse oximeter Coverage Update | Op…
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    CurrentnorthwoodPolicy N/A

    Home pulse oximeter (pulse oximetry) for outpatient/home use

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    Defines Northwood coverage and medical necessity criteria for home pulse oximeters and replacement probes for Medicare and non‑Medicare members, with special pediatric indications and exclusions.

    Policy Summary
    Payernorthwood
    PolicyHome pulse oximeter (pulse oximetry) for outpatient/home use
    Policy CodePolicy N/A
    Change TypeAnnual review — no material changes
    Effective DateJan 1, 2021
    Last ReviewDec 9, 2021
    Next Review DateApr 12, 2025
    Key ActionOrder device and document trained caregiver availability and clinical indication to support authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    E0445, A4606HCPCS codes listed
    ≤1 moStandard rental limit
    ≤6 moInfant rental limit
    ≤1 yrPediatric age group
    1

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    NH Medicaid criterion sets
    21Revision entries

    Coverage criteria and limitations

    Coverage criteria (general and continuous use)

    Covered when ALL of the following are met:

    General requirements: Must be ordered by the member's treating practitioner.
    Continuous home pulse oximetry prerequisites: A trained caregiver should be available to respond to changes in oxygen saturation AND device should include an event recorder AND rental duration limits apply (standard: one-month rental; up to six months for infants continuing on oxygen or with a tracheostomy).

    Pediatric indications (newborns and children up to one year)

    Considered an established option if ALL of the following apply and a trained caregiver is available:

    Pediatric indications (newborns and children up to one year): a. Diagnosed with a chronic respiratory or cardiovascular disease requiring continuous oxygen supplementation; b. Oxygen need varies from day to day or per activity (e.g., feeding, sleeping, movement); c. Medical need exists to maintain oxygen saturation within a narrow range; d. Infants who have experienced an apparent life-threatening event (ALTE); e. Infants with tracheostomies or anatomical abnormalities that make them vulnerable to airway compromise; f. Infants with neurologic or metabolic disorders affecting respiratory control; g. Infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous airway pressure or mechanical ventilation; h. Infant with a craniofacial anomaly or a neuromuscular disorder which results in upper airway obstruction; i. Infant at high risk for hypoxic events.

    Any one of the listed indications plus caregiver availability and practitioner order suffices.

    The use of home pulse oximetry is considered experimental/investigational and not established for the indications listed in this policy because effectiveness has not been demonstrated. Specific excluded uses include: prevention of sudden infant death syndrome (SIDS); use in members over one year of age (except where plan‑specific guidance such as NH Medicaid may differ); asthma management; diagnosing nocturnal hypoventilation associated with neuromuscular disorders; evaluating or teaching continuous positive airway pressure (CPAP); evaluation of exertional desaturation in individuals with COVID‑19; screening or diagnostic testing for obstructive sleep apnea or other sleep disturbance; maintenance or continuous monitoring of members (other than for persons on a ventilator); and predicting the need for adenotonsillectomy in children.

    Revision history documents that multiple prior reviews have labeled specific home pulse oximetry uses as experimental/investigational. Earlier entries note additions and clarifications over time, including the 2017 revision that explicitly identified prediction of adenotonsillectomy need as experimental, and later updates (e.g., 2022) that added evaluation of exertional desaturation (a ≥3% fall on exercise) in individuals with COVID‑19 to the exclusions.

    Home pulse oximetry is considered not reasonable and necessary for the excluded indications listed above due to insufficient clinical evidence supporting benefit in the home setting. These exclusions should be applied when evaluating requests for devices or replacement probes for these purposes.

    Codes, billing and rental rules

    HCPCS Level II CodesHCPCS
    E0445Oximeter device for measuring blood oxygen levels non-invasively.
    A4606Oxygen probe for use with oximeter device, replacement.
    Rental duration for continuous monitoring
    Standard rental durationLimited to one-month rental for continuous home pulse oximetry.
    Extended rental for infantsUp to six months rental for infants continuing on supplemental oxygen or who have a tracheostomy.
    Device requirementDevice should include an event recorder when used for continuous home monitoring.
    Caregiver requirementContinuous monitoring requires a trained caregiver available to respond to changes in oxygen saturation.

    Prior authorization, ordering and payer-specific actions

    Prior Authorization

    Prior authorization and rental limits

    Prior authorization may be required per plan for home oximeters (E0445) and replacement probes (A4606). Rental for continuous home pulse oximetry is limited to one month, except infants who continue on supplemental oxygen or have a tracheostomy may be rented up to six months.

    • Codes: E0445 (oximeter device) and A4606 (replacement oxygen probe).
    • Standard rental limit: one month.
    • Infant exception: up to six months if continuing on oxygen or with tracheostomy.
    Prior Authorization

    NH Medicaid prior authorization requirement

    NH Medicaid requires prior authorization; authorization will be granted only when one of three specified clinical criteria is documented.

    • a. Recipient is being assessed by primary care practitioner or pulmonary specialist to determine if supplemental oxygen is required.
    • b. Recipient has been on supplemental oxygen and the oximeter is requested to determine if they can be weaned.

    Medical necessity criteria

    Medical necessity for continuous home pulse oximetry

    Core: Ordered by treating practitioner AND trained caregiver available to respond to desaturation events AND device includes an event recorder; rental duration limits apply (standard one-month rental; up to six months for infants continuing on oxygen or with a tracheostomy).
    Pediatric indications: Any one of the pediatric indications (a–i) for newborns and children up to one year of age suffices when combined with the above core requirements.

    NH Medicaid criteria

    NH Medicaid medical necessity — authorization will be given when ANY of the following are met:

    NH Medicaid authorization criteria: 1) Recipient is being assessed by a primary care practitioner or pulmonary specialist to determine if supplemental oxygen is required; OR 2) Recipient has been on supplemental oxygen and an oximeter is requested to determine if he or she can be weaned from the supplemental oxygen; OR 3) Recipient is receiving supplemental oxygen and is experiencing widely fluctuating oxygen saturation levels and an oximeter is required to assist in determining the cause, frequency, and duration of the fluctuation to properly determine the oxygen flow rate.

    Rental, purchase and device rules

    EquipmentRuleNotes
    Continuous home pulse oximetry device (E0445)RentalLimited to one-month rental standard; up to six months for infants continuing on oxygen or with a tracheostomy.
    Replacement oxygen probe (A4606)RentalSubject to same rental limitations when billed as rental accessories; prior authorization may be required per plan.

    Required documentation and supporting evidence

    Documentation Required

    Order, caregiver availability, pediatric indication, and rental need (contract governs benefit)

    Obtain an order from the treating practitioner and document caregiver availability, the pediatric indication per criteria (if applicable), and the need for continuous monitoring or specific rental duration; final benefit determination depends on the member’s contract language.

    • Order from treating practitioner is required.
    • Document trained caregiver availability and justification per pediatric criteria when applicable.
    • Document need for continuous monitoring and requested rental duration; contract language governs final benefit.
    Documentation Required

    Provide clinical documentation supporting NH Medicaid criteria

    Provide clinical documentation that supports one of the NH Medicaid criteria: assessment for supplemental oxygen need, documentation that an oximeter is requested for weaning from oxygen, or evidence of widely fluctuating saturations while on oxygen.

    Key definitions

    Pulse oximeter definition
    DefinitionA noninvasive device consisting of a sensor attached to finger, nose, ear, or toe linked to a processing unit that measures arterial oxygen saturation and pulse rate.
    FunctionMeasures oxygen saturation of hemoglobin in arterial blood and pulse rate by detecting light absorption at two wavelengths and pulsatile changes.
    OutputProvides a rapid readout indicating an individual’s level of oxygenation for clinical monitoring.

    Clinical background and rationale

    Pulse oximetry noninvasively estimates arterial hemoglobin oxygen saturation and pulse rate by measuring light absorption at two wavelengths. A pulse oximeter consists of a sensor applied to a finger, nose, ear, or toe that transmits photoplethysmographic signals to a processing unit, providing a rapid indication of oxygenation and pulse which can be used to monitor patients' oxygen status in the home setting.

    Non-covered indications

    For Medicare members, note that oximeters (HCPCS E0445) and replacement probes (HCPCS A4606) are considered non‑covered under Medicare guidance because they are monitoring devices that furnish information to physicians to assist in managing treatment. Separately, home pulse oximetry is not covered for the experimental/investigational indications listed in this policy (see exclusions).

    The revision history records that certain uses have been added over time to the experimental/investigational list. Notable historical entries include the 2017 update identifying prediction of adenotonsillectomy as experimental, and the 2022 update adding evaluation of exertional desaturation (a ≥3% fall on exercise) in people with COVID‑19 to the exclusions.

    Policy Summary
    Payernorthwood
    PolicyHome pulse oximeter (pulse oximetry) for outpatient/home use
    Policy CodePolicy N/A
    Change TypeAnnual review — no material changes
    Effective DateJan 1, 2021
    Last ReviewDec 9, 2021
    Next Review DateApr 12, 2025
    Key ActionOrder device and document trained caregiver availability and clinical indication to support authorization.
    SourceLink
    On This Page
    Coverage criteria and limitationsCodes, billing and rental rulesPrior authorization, ordering and payer-specific actionsMedical necessity criteriaRental, purchase and device rulesRequired documentation and supporting evidenceKey definitionsClinical background and rationaleNon-covered indications
  1. c. Recipient is on supplemental oxygen and has widely fluctuating oxygen saturation levels requiring monitoring to determine cause, frequency, and duration to set oxygen flow rate.
    2. Documentation Required

    Order and device requirements

    Ensure the device ordered includes an event recorder and that the order is placed by the treating practitioner; document these elements in the patient record.

    • Device should include an event recorder.
    • Order must be from the member's treating practitioner.
    Documentation Required

    Caregiver availability requirement

    Confirm and document caregiver availability — a trained caregiver must be available to respond to changes in oxygen saturation for continuous home pulse oximetry to be considered.

    • Document that a trained caregiver is available to respond to desaturation events.
    Documentation Required

    Order and caregiver availability

    Orders must be from the treating practitioner and documentation must support caregiver availability, the indicated pediatric criteria when applicable, and the clinical need for continuous monitoring or the requested rental duration.

    • Include practitioner order in the record.
    • Document caregiver availability and training.
    • For pediatrics, document which one of the pediatric indications (a–i) applies.
    • Support the requested rental duration (one month standard; up to six months for eligible infants).
    Documentation Required

    Documentation to support NH Medicaid authorization

    For NH Medicaid authorization, provide clinical documentation showing the recipient meets one of the NH Medicaid criteria (assessment for supplemental oxygen need; weaning assessment; or widely fluctuating saturations while on supplemental oxygen).

    • Document assessment by primary care practitioner or pulmonary specialist for supplemental oxygen need.
    • Or document that the oximeter is requested to determine ability to wean from supplemental oxygen.
    • Or document widely fluctuating oxygen saturation levels while on supplemental oxygen and need to determine cause, frequency, and duration.
    Denial Risk

    Medicare non-coverage triggers

    For Medicare members, oximeters (E0445) and replacement probes (A4606) are considered non-covered under Medicare guidelines because they are monitoring devices that provide information to physicians to assist in managing treatment.

    • Do not expect Medicare coverage for E0445 or A4606 per Medicare policy references (L33797, A52514).
    Note

    NH Medicaid authorization triggers

    NH Medicaid will authorize only when documentation shows one of the three specified clinical situations is met: assessment for oxygen need, weaning assessment, or monitoring widely fluctuating saturations while on supplemental oxygen.

    • Authorization trigger: assessment by PCP or pulmonary specialist for supplemental oxygen requirement.
    • Authorization trigger: oximeter requested to determine ability to wean from supplemental oxygen.
    • Authorization trigger: monitoring required for widely fluctuating oxygen saturations on supplemental oxygen to determine appropriate flow rate.

    From NH Medicaid special coverage information.