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3.5.5.2.2 Pulse Oximeter
A pulse oximeter requires prior authorization.
A pulse oximeter may be considered for prior authorization for clients who are birth through 20 years of age who meet the following criteria for the level requested:
• Level One. Basic level monitoring capable of spot checks and heart rate. Applicable if there is a caregiver and/or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way and the client meets at least one the of the following criteria:
•Client is oxygen- and/or ventilator-dependent (Less than 8 hours per day).
•Client is clinically stable and able to wean from oxygen and/or ventilator.
•Client has other medically necessary condition(s) requiring monitoring of oxygen saturation.
•Level Two. Providers must use modifier TF when the oximeter device is for intermediate level of care and continuous monitoring, alarm, memory, and correction of motion artifact. Applicable if the client meets all the following criteria:
•Client is oxygen- and/or ventilator-dependent a significant portion of the day (e.g., 8 to 16 hours per day).
•Client needs continuous monitoring of oxygen saturation during sleep and/or to maintain optimal levels.
•There is a caregiver and/or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.
•Level Three. Providers must use modifier TG if the oximeter device is for a serious condition and there is critical need for continuous monitoring. Applicable if the client meets all the following criteria:
•Client has frequent need for changes in oxygen and ventilator settings.
•Client is oxygen- and/or ventilator-dependent (e.g., 16 to 24 hours per day).
•Client is in the weaning process from oxygen and/or ventilator and experiencing respiratory complications.
•Client requires equipment that is motion-sensitive or that has more complex readouts or monitoring capabilities.
•There is a caregiver and/or medical provider identified and present who has been trained in use of the oximeter and how to respond to readings in a medically safe way.
For all requests providers must:
•Submit the completed Form CH.11, "Pulse Oximeter Form" and Form CH.1, "CCP Prior Authorization Request Form" in this handbook.
•Clearly indicate medical necessity using the TF and TG modifiers on the Pulse Oximeter Form.
•Continue to use the current code for lease (E0445 with modifier RR) and purchase (E0445 with modifier NU).
A pulse oximeter rental includes the system, the sensor probes, and all necessary supplies.
Pulse oximeter sensor probes (procedure code A4606) for client-owned equipment are limited to 4 per month without prior authorization. Providers may obtain additional probes for clients birth through 20 years of age with documentation of medical necessity. Additional probes require prior authorization through CCP.
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