Or. Admin. Code § 410-122-0200

Current through Register Vol. 63, No. 12, December 1, 2024

Section 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 practitioner;

(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 practitioner; 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 practitioner 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:

(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.

Or. Admin. Code § 410-122-0200

HR 13-1991, f. & cert. ef. 3-1-91; HR 10-1992, f. & cert. ef. 4-1-92; HR 32-1992, f. & cert. ef. 10-1-92; HR 9-1993 f. & cert. ef. 4-1-93; HR 10-1994, f. & cert. ef. 2-15-94; HR 26-1994, f. & cert. ef. 7-1-94; HR 41-1994,. f. 12-30-94, cert. ef. 1-1-95; HR 17-1996, f. & cert. ef. 8-1-96; HR 7-1997, f. 2-28-97, cert. ef. 3-1-97; OMAP 11-1998, f. & cert. ef. 4-1-98; OMAP 13-1999, f. & cert. ef. 4-1-99; OMAP 32-1999, f. & cert. ef. 10-1-99; OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 8-2002, f. & cert. ef. 4-1-02; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 25-2004, f. & cert. ef. 4-1-04; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06; DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065