CSHCN Services Program 2010 > Respiratory Equipment and Supplies > Benefits, Limitations, and Authorization Requirements

33.2.9 Pulse Oximeters

Pulse oximeters require prior authorization. A completed CSHCN Services Program Prior Authorization Request for Pulse Oximeter Devices form, which can be found on page B-65 must be submitted with documentation of medical necessity.

Simple nonrecording oximeters may be billed using procedure code E0445. Recording pulse oximeters may be billed using procedure code E0445 with modifier TF.

The rental of pulse oximeters includes the probes.

Oximeters may be reimbursed for a rental period of up to 6 months. Extensions will be considered with documentation of medical necessity. Purchase may be considered with documentation of medical necessity.

Pulse oximeters may be prior authorized for clients who meet the following criteria:

Procedure Code E0445

•Client is oxygen or ventilator dependent, or

•Client is clinically stable and is weaning off the oxygen or ventilator, or

•Client has another condition that requires monitoring of oxygen saturation.

Client does not usually require continuous or long-term monitoring. Client usually requires only spot checks for oxygen saturation.

Procedure Code E0445 with Modifier TF

•Client is oxygen- or ventilator-dependent, and

•Client needs continuous monitoring or monitoring during sleep, or

•Client needs continuous monitoring to maintain optimal oxygen saturation levels, and

•There is a caregiver who has been identified, and is present, and has been trained in the use of the oximeter and how to respond to readings in a medically safe way.

•Client is clinically unstable or just returned home from a hospital stay.