OAR 410-122-0200
Pulse Oximeter for Home Use

(1)

Indications and limitations of coverage and medical appropriateness:

(a)

The Division may cover a tamper-proof pulse oximeter for home use when all of the following criteria are met:

(A)

The client has frequently fluctuating oxygen saturation levels that are clinically significant;

(B)

Measurements are integral in dictating acute therapeutic intervention;

(C)

The absence of readily available saturation measurements represents an immediate and demonstrated health risk;

(D)

The client has a caregiver trained to provide whatever care is needed to reverse the low oxygen saturation level ordered by the physician;

(b)

Some examples of when a home pulse oximeter may be covered include the following:

(A)

When weaning a client from home oxygen or a ventilator;

(B)

When a change in the client’s physical condition requires an adjustment in the liter flow of their home oxygen needs;

(C)

To determine appropriate home oxygen liter flow for ambulation, exercise, or sleep;

(D)

To monitor a client on mechanical ventilation at home;

(E)

To periodically re-assess the need for long-term oxygen in the home;

(F)

Infants with chronic lung disease (e.g., bronchopulmonary dysplasia);

(G)

Premature infants on active therapy for apnea;

(H)

When a client exhibits a certain unstable illness and has compromised or potentially compromised respiratory status;

(I)

When evidence-based clinical practice guidelines support the need;

(c)

Home pulse oximetry for indications other than those listed above may be covered on a case-by-case basis upon medical review by the Division’s Policy Unit;

(d)

The durable medical equipment prosthetics, orthotics and supplies (DMEPOS) provider is responsible to ensure the following services for home pulse oximetry rental are provided:

(A)

For purchase or rental of a pulse oximeter for home use:
(i)
Training regarding the use and care of the equipment and care of the client as it relates to the equipment, including progressive intervention and cardiopulmonary resuscitation (CPR) training prior to use of the equipment by the client; and
(ii)
A follow-up home visit within the first 30 days of equipment setup to ensure a CPR/emergency area has been designated; and

(B)

For rental of a pulse oximeter for home use:
(i)
Monthly telephone follow-up and support to ensure caregivers are using the equipment as ordered by the physician; and
(ii)
24-hour/7 day a week respiratory therapist on-call availability for troubleshooting, exchanging of malfunctioning equipment, etc.;
(iii)
The allowable rental fee includes all equipment, supplies, services, including all probes, routine maintenance and necessary training for the effective use of the pulse oximeter;

(e)

The Division may cover probes for a client-owned covered oximeter:

(A)

The Division will reimburse for the least costly alternative for payment of probes, whether disposable or reusable, which meets the medical need of the client;

(B)

A reusable probe must be used when it is the least costly alternative rather than a disposable probe, unless the client’s medical records clearly substantiates why a reusable probe is contraindicated;

(C)

Disposable probes (oxisensors) may be reused on the same client as long as the adhesive attaches without slippage;

(f)

The use of home pulse oximetry for indications considered experimental and investigational, including the following, are not covered:

(A)

Asthma management;

(B)

When used alone as a screening/testing technique for suspected obstructive sleep apnea;

(C)

Routine use (e.g., client with chronic, stable cardiopulmonary condition).

(2)

Documentation Requirements:

(a)

Submit the following documentation for prior authorization (PA) review:

(A)

An order from the treating physician that clearly specifies the medical appropriateness for home pulse oximetry testing;

(B)

Documentation of signs/symptoms/medical condition exhibited by the client, that require continuous pulse oximetry monitoring as identified by the need for oxygen titration, frequent suctioning or ventilator adjustments, etc.;

(C)

Plan of treatment that identifies a trained caregiver is available to perform the testing, document the frequency and the results and implement the appropriate therapeutic intervention, when necessary;

(D)

For probes for a client-owned oximeter, documentation that probes requested are the least costly alternative;

(E)

Other medical records that corroborate conditions for coverage are met as specified in this rule;

(b)

History and physical exam and progress notes must be available for review by the Division, upon request.

(3)

Procedure Codes:

(a)

A4606 — Oxygen probe for use with client-owned oximeter device, replacement:

(A)

PA required;

(B)

The Division will purchase;

(b)

E0445 — Oximeter device for measuring blood oxygen levels non-invasively:

(A)

PA required;

(B)

The Division will purchase or rent on a monthly basis;

(C)

The Division will repair a client-owned, covered pulse oximeter when cost effective;

(D)

Item considered purchased after seven months of rent;

(E)

Quantity (units) is one on a given date of service.

Source: Rule 410-122-0200 — Pulse Oximeter for Home Use, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0200.

410–122–0010
Definitions 410–122–0020
Orders 410–122–0040
Prior Authorization 410–122–0080
Conditions of Coverage, Limitations, and Restrictions 410–122–0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410–122–0180
Healthcare Common Procedure Coding System Level II Coding 410–122–0182
Legend 410–122–0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410–122–0186
Payment Methodology 410–122–0188
DMEPOS Rebate Agreements 410–122–0200
Pulse Oximeter for Home Use 410–122–0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410–122–0203
Oxygen and Oxygen Equipment 410–122–0204
Nebulizer 410–122–0205
Respiratory Assist Devices 410–122–0206
Intermittent Positive Pressure Breathing 410–122–0207
Respiratory Supplies 410–122–0208
Suction Pumps 410–122–0209
Tracheostomy Care Supplies 410–122–0210
Ventilators 410–122–0211
Cough Stimulating Device 410–122–0220
Pacemaker Monitor 410–122–0240
Apnea Monitors for Infants 410–122–0250
Breast Pumps 410–122–0260
Home Uterine Monitoring 410–122–0280
Heating/Cooling Accessories 410–122–0300
Light Therapy 410–122–0320
Manual Wheelchair Base 410–122–0325
Power Wheelchair Base 410–122–0330
Power-Operated Vehicle 410–122–0340
Wheelchair Options/Accessories 410–122–0360
Canes and Crutches 410–122–0365
Standing and Positioning Aids 410–122–0375
Walkers 410–122–0380
Hospital Beds 410–122–0400
Pressure Reducing Support Surfaces 410–122–0420
Hospital Bed Accessories 410–122–0475
Therapeutic Shoes for Diabetics 410–122–0510
Osteogenesis Stimulator 410–122–0515
Neuromuscular Electrical Stimulator (NMES) 410–122–0520
Glucose Monitors and Diabetic Supplies 410–122–0525
External Insulin Infusion Pump 410–122–0540
Ostomy Supplies 410–122–0560
Urological Supplies 410–122–0580
Bath Supplies 410–122–0590
Patient Lifts 410–122–0600
Toilet Supplies 410–122–0620
Miscellaneous Supplies 410–122–0625
Surgical Dressing 410–122–0630
Incontinent Supplies 410–122–0640
Eye Prostheses 410–122–0655
External Breast Prostheses 410–122–0658
Gradient Compression Stockings/Sleeves 410–122–0660
Orthotics and Prosthetics 410–122–0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410–122–0678
Dynamic Adjustable Extension/Flexion Device 410–122–0680
Facial Prostheses 410–122–0700
Negative Pressure Wound Therapy Pumps 410–122–0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0200’s source at or​.us