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Clinical Policy Bulletin:
Pulse Oximetry for Home Use
Number: 0339


Policy

  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.



Background

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).

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria is met:
94760
94761
94762
CPT codes related to the CPB:
94660
HCPCS codes covered if selection criteria are met:
A4606 Oxygen probe for use with oximeter device, replacement
E0445 Oximeter device for measuring blood oxygen levels non-invasively
Other HCPCS codes related to the CPB:
E0424 - E0444, E0450 - E0484 Oxygen and related respiratory equipment
ICD-9 codes covered if selection criteria are met (not all-inclusive):
277.00 - 277.09 Cystic fibrosis
289.0 Polycythemia, secondary
413.0 - 413.9 Angina pectoris
416.0 - 416.9 Chronic pulmonary heart disease
428.0 Congestive heart failure, unspecified
443.9 Peripheral vascular disease, unspecified
492.0 - 492.8 Emphysema
494.0 - 494.1 Bronchiectasis
496 Chronic obstructive pulmonary disease
515 Postinflammatory pulmonary fibrosis
518.51 - 518.53 Pulmonary insufficiency following trauma and surgery
746.7 Hypoplastic left heart syndrome [for interstage monitoring of children undergoing the Norwood procedure]
769 Respiratory distress syndrome
770.0 - 770.89 Other respiratory conditions of fetus and newborn
786.03 Apnea
799.02 Hypoxemia
V46.1 Dependence on respirator [Ventilator]
V46.2 Dependence on supplemental oxygen
ICD-9 codes not covered for indications listed in the CPB (not all inclusive):
327.24 Idiopathic sleep related nonobstructive alveolar hypoventilation [nocturnal hypoventilation]
327.26 Sleep related hypoventilation/hypoxemia in conditions classifiable elsewhere [nocturnal hypoventilation]
493.00 - 493.92 Asthma
780.50 - 780.59 Sleep disturbances
V81.4 Special screening for other and unspecified respiratory conditions


The above policy is based on the following references:
  1. American Association for Respiratory Care (AARC). AARC clinical practice guideline. Oxygen therapy in the home or extended care facility. Respir Care. 1992;37(8):918-922.
  2. National Heart, Lung and Blood Institute (NHLBI) and World Health Organization (WHO). Global Strategy for Asthma Management and Prevention NHLBI/WHO Workshop (based on a March 1993 meeting). Publication Number 95-3659. Bethesda, MD: National Institutes of Health; January 1995.
  3. Series F, Marc I, Cormier Y, et al. Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome. Ann Int Med. 1993;119:449-453.
  4. Farney RJ, Walker LE, Jensen RL, et al. Ear oximetry to detect apnea and differentiate rapid eye movement (REM) and non-REM sleep. Screening for the sleep apnea syndrome. Chest. 1986;89:533-539.
  5. Ferber R, Millman R, Coppola M, et al. Portable recording in the assessment of obstructive sleep apnea. ASDA Standards of Practice. Sleep. 1994;17:378-392.
  6. American Association for Respiratory Care (AARC). AARC clinical practice guideline. Pulse oximetry. Respir Care. 1991;36(12):1406-1409.
  7. National Institutes of Health. Infantile apnea and home monitoring. Natl Inst Health Consens Dev Conf Consens Statement. 1986;6(6):1-10.
  8. Ringbaek TJ, Lange P, Viskum K. Are patients on long-term oxygen therapy followed up properly? Data from the Danish Oxygen Register. J Intern Med. 2001;250(2):131-136.
  9. Golpe R, Jimenez A, Carpizo R, et al. Utility of home oximetry as a screening test for patients with moderate to severe symptoms of obstructive sleep apnea. Sleep. 1999;22(7):932-937.
  10. Evans SE, Scanlon PD. Current practice in pulmonary function testing. Mayo Clin Proc. 2003;78(6):758-763.
  11. Lewis CA, Eaton TE, Fergusson W, et al. Home overnight pulse oximetry in patients with COPD: More than one recording may be needed. Chest. 2003;123(4):1127-1133.
  12. Gay PC. Chronic obstructive pulmonary disease and sleep. Respir Care. 2004;49(1):39-51; discussion 51-52.
  13. Valentine VG, Taylor DE, Dhillon GS, et al. Success of lung transplantation without surveillance bronchoscopy. J Heart Lung Transplant. 2002;21(3):319-326.
  14. Whitelaw WA, Brant RF, Flemons WW. Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea. Am J Respir Crit Care Med. 2005;171(2):188-193.
  15. Series F, Kimoff RJ, Morrison D, et al. Prospective evaluation of nocturnal oximetry for detection of sleep-related breathing disturbances in patients with chronic heart failure. Chest. 2005;127(5):1507-1514.
  16. Foo JY, Lim CS. Development of a home screening system for pediatric respiratory sleep studies. Telemed J E Health. 2006;12(6):698-701.
  17. Gélinas JF, Davis GM, Arlegui C, Côté A. Prolonged, documented home-monitoring of oxygenation in infants and children. Pediatr Pulmonol. 2008;43(3):288-296. 
  18. Nassi N, Piumelli R, Lombardi E, et al. Comparison between pulse oximetry and transthoracic impedance alarm traces during home monitoring. Arch Dis Child. 2008;93(2):126-132.
  19. Ghanayem NS, Hoffman GM, Mussatto KA, et al. Home surveillance program prevents interstage mortality after the Norwood procedure. J Thorac Cardiovasc Surg. 2003;126(5):1367-1377.
  20. Hansen JH, Furck AK, Petko C, et al. Use of surveillance criteria reduces interstage mortality after the Norwood operation for hypoplastic left heart syndrome. Eur J Cardiothorac Surg.
    2012;41(5):1013-1018.
  21. Dobrolet NC, Nieves JA, Welch EM, et al. New approach to interstage care for palliated high-risk patients with congenital heart disease. J Thorac Cardiovasc Surg. 2011;142(4):855-860.
  22. Nardi J, Prigent H, Adala A, et al. Nocturnal oximetry and transcutaneous carbon dioxide in home-ventilated neuromuscular patients. Respir Care. 2012;57(9):1425-1430.
  23. Bauman KA, Kurili A, Schmidt SL, et al. Home-based overnight transcutaneous capnography/pulse oximetry for diagnosing nocturnal hypoventilation associated with neuromuscular disorders. Arch Phys Med Rehabil. 2013;94(1):46-52.
  24. Epstein SK. Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2013a.
  25. Epstein SK. Respiratory muscle weakness due to neuromuscular disease: Management. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2013b.
  26. Bach JR. Continuous noninvasive ventilatory support for patients with neuromuscular or chest wall disease. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2013.
  27. Hill NS, Kramer NR. Types of noninvasive nocturnal ventilatory support in neuromuscular and chest wall disease. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed February 2013.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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