1. Aetna considers a pulse oximeter for home use medically necessary durable medical equipment (DME) for members with any of the following indications:

   1. To determine appropriate home oxygen liter flow for ambulation, exercise, or sleep; or
   2. To monitor individuals on a ventilator at home; or
   3. When a change in the individual's physical condition requires an adjustment in the liter flow of their home oxygen needs; or
   4. When weaning the individual from home oxygen; or
   5. For interstage monitoring of children undergoing the Norwood procedure for hypoplastic left heart syndrome.

   For information on the use of pulse oximetry in periodically re-assessing the need for long-term oxygen in the home, see CPB 0002 - Oxygen.  Pulse oximetry can be used in conjunction with infant home apnea monitoring; for information on infant apnea monitors, see CPB 0003 - Apnea Monitors for Infants.  Home pulse oximetry for indications other than those listed above may be considered medically necessary upon medical review.

2. Aetna considers the use of home pulse oximetry experimental and investigational for all other indications, including the following because its effectiveness for these indications has not been established:

   1. Asthma management
   2. Diagnosing nocturnal hypoventilation associated with neuromuscular disorders 
   3. Evaluating and teaching continuous positive airway pressure (CPAP)
   4. When used alone as a screening/testing technique for suspected obstructive sleep apnea.

See also CPB 0004 - Obstructive Sleep Apnea in Adults, CPB 0479 - Respiratory Devices: Incentive Spirometers and Intermittent Positive Pressure Breathing Machines, and CPB 0572 - Home/Ambulatory Spirometry.

For patients on long-term oxygen therapy, pulse oximetry arterial oxygen saturation (SaO2) measurements are unnecessary except to assess changes in clinical status, or to facilitate changes in the oxygen prescription.  Home pulse oximetry is also indicated when there is a need to monitor the adequacy of SaO2 or the need to quantitate the response of SaO2 to a therapeutic intervention.

A National Heart, Lung and Blood Institute/World Health Organization Global Asthma Initiative Report concluded that pulse oximetry was not an appropriate method of monitoring patients with asthma.  The report explained that, during asthma exacerbations, the degree of hypoxemia may not accurately reflect the underlying degree of ventilation-perfusion (V-Q) mismatch.  Pulse oximetry alone is not an efficient method of screening or diagnosing patients with suspected obstructive sleep apnea (OSA).  The sensitivity and negative predictive value of pulse oximetry is not adequate to rule out OSA in patients with mild to moderate symptoms.  Therefore, a follow-up sleep study would be required to confirm or exclude the diagnosis of OSA, regardless of the results of pulse oximetry screening.

Home overnight pulse oximetry (OPO) has been used to evaluate nocturnal desaturation in patients with chronic obstructive pulmonary diseases (COPD).  However, Lewis et al (2003) found that nocturnal desaturation in patients with COPD exhibited marked night-to-night variability when measured by home OPO.  A single home OPO recording may be insufficient for accurate assessment of nocturnal desaturation.  Gay (2004) stated that for COPD patients who exhibit more profound daytime hypercapnia, polysomnography is preferred over nocturnal pulse oximetry to rule out other co-existing sleep-related breathing disorders such as OSA (overlap syndrome) and obesity hypoventilation syndrome.

In a retrospective case-series study, Bauman et al (2013) determined the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco(2)) monitoring/oxygen saturation by pulse oximetry (Spo(2)) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders.  Subjects (n = 35, 68.6 % men; mean age of 46.9 yrs) with spinal cord injury (45.7 %) or other neuromuscular disorders underwent overnight tests with tc-Pco(2)/Spo(2) monitoring.  Fifteen (42.9 %) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV).  A respiratory therapist brought a calibrated tc-Pco(2)/Spo(2) monitor to the patient's home and provided instructions for data collection during the subject's normal sleep period.  Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco(2) (ET-Pco(2)) were recorded at a clinic visit before monitoring.  Main outcome measure was detection of NH (tc-Pco(2) greater than or equal to 50 mmHg for greater than or equal to 5 % of monitoring time).  Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo(2) less than or equal to 88 % for greater than or equal to 5 % of monitoring time), FVC, BMI, or daytime ET-Pco(2) could predict the presence of NH.  Nocturnal hypoventilation was detected in 18 subjects (51.4 %), including 53.3 % of those using BiPAP or TV.  Nocturnal hypoventilation was detected in 43.8 % of ventilator-independent subjects with normal daytime ET-Pco(2) (present for 49.4 % +/- 31.5 % [mean +/- SD] of the study period), and in 75 % of subjects with an elevated daytime ET-Pco(2) (present for 92.3 % +/- 8.7 % of the study period).  Oxygen desaturation, BMI, and FVC were poor predictors of NH.  Only 3 attempted monitoring studies failed to produce acceptable results.  The authors concluded that home-based, unsupervised monitoring with tc-Pco(2)/Spo(2) is a useful method for diagnosing NH in neuromuscular respiratory failure (NMRF).  The findings of this small retrospective case-series study need to be validated by well-designed studies.

Nardi et al (2012) noted that pulse oximetry alone has been suggested to determine which patients on home mechanical ventilation (MV) require further investigation of nocturnal gas exchange.  In patients with neuromuscular diseases, alveolar hypoventilation (AH) is rarely accompanied with ventilation-perfusion ratio heterogeneity, and, therefore, oximetry may be less sensitive for detecting AH than in patients with lung disease.  These investigators examined if Spo(2) and tc-Pco(2) during the same night were interchangeable or complementary for assessing home MV efficiency in patients with neuromuscular diseases.  Data were collected retrospectively from the charts of 58 patients with chronic NMRF receiving follow-up at a home MV unit.  Spo(2) and tc-Pco(2) were recorded during a 1-night hospital stay as part of standard patient care.  These researchers compared AH detection rates by tc-Pco(2), Spo(2), and both.  Alveolar hypoventilation was detected based on tc-Pco(2) alone in 24 (41 %) patients, and based on Spo(2) alone with 3 different cut-offs in 3 (5 %), 8 (14 %), and 13 (22 %) patients, respectively.  Using both tc-Pco(2) and Spo(2) showed AH in 25 (43 %) patients.  The authors concluded that pulse oximetry alone is not sufficient to exclude AH when assessing home MV efficiency in patients with neuromuscular diseases.  Both tc-Pco(2) and Spo(2) should be recorded overnight as the first-line investigation in this population.

Also, UpToDate reviews on "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation" (Epstein, 2013a); "Respiratory muscle weakness due to neuromuscular disease: Management" (Epstein, 2013b); "Continuous noninvasive ventilatory support for patients with neuromuscular or chest wall disease" (Bach, 2013), and "Types of noninvasive nocturnal ventilatory support in neuromuscular and chest wall disease" (Hill and Kramer, 2013) do not mention the use of home pulse oximetry.

Studies have demonstrated improvements in survival of infants undergoing the Norwood procedure for hypoplastic left heart syndrome with interstage monitoring with home pulse oximetry (Ghanayem, et al., 2003; Dobrolet, et al., 2011; Hansen, et al., 2012).