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 (calibrated, preset, and sealed) 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 monitor a client with a tracheostomy at home; (F) To periodically re-assess the need for long-term oxygen in the home; (G) Infants with chronic lung disease (e.g., bronchopulmonary dysplasia); (H) Premature infants on active therapy for apnea; (I) When a client exhibits a certain unstable illness and has compromised or potentially compromised respiratory status or airways; (J) 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 are provided: (A) For purchase or rental of a pulse oximeter for home use: (i) Training client or caregiver on the use and care of the equipment and developing an emergency plan, such as dialing immediate emergency services, are performed at the time of delivery or prior to equipment usage; and (ii) A follow-up telephone call or home visit is conducted within the first 30 days of equipment setup to ensure client’s continuation and proper use of the equipment; (B) For rental of a pulse oximeter for home use: (i) 24-hour/7 day a week respiratory therapist on-call availability for troubleshooting, exchanging of malfunctioning equipment, etc.; and (ii) 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 replacement probes for a client-owned covered oximeter as ordered by the treating practitioner for continued use: (A) The Division shall 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 substantiate 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 of which type of probes are prescribed and why the 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) For adults, PA is 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 (7) months of rent; (E) Quantity (units) is one on a given date of service. (4) Refer to Coverage Table OAR 410-122-0203-1. Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 87-2025, amend filed 12/09/2025, effective 12/09/2025 DMAP 101-2023, amend filed 12/29/2023, effective 01/01/2024 DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09 OMAP 35-2006, f. 9-15-06, cert. ef. 10-1-06 OMAP 11-2005, f. 3-9-05, cert. ef. 4-1-05 OMAP 44-2004, f. & cert. ef. 7-1-04 OMAP 25-2004, f. & cert. ef. 4-1-04 OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03 OMAP 47-2002, f. & cert. ef. 10-1-02 OMAP 8-2002, f. & cert. ef. 4-1-02 OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01 OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00 OMAP 1-2000, f. 3-31-00, cert. ef. 4-1-00 OMAP 32-1999, f. & cert. ef. 10-1-99 OMAP 13-1999, f. & cert. ef. 4-1-99 OMAP 11-1998, f. & cert. ef. 4-1-98 HR 7-1997, f. 2-28-97, cert. ef. 3-1-97 HR 17-1996, f. & cert. ef. 8-1-96 HR 41-1994, f. 12-30-94, cert. ef. 1-1-95 HR 26-1994, f. & cert. ef. 7-1-94 HR 10-1994, f. & cert. ef. 2-15-94 HR 9-1993, f. & cert. ef. 4-1-93 HR 32-1992, f. & cert. ef. 10-1-92 HR 10-1992, f. & cert. ef. 4-1-92 HR 13-1991, f. & cert. ef. 3-1-91