5101:3-10-23 Pulse oximeters.

(A) A pulse oximeter is a covered medical equipment item eligible for reimbursement when used in a personal residence as an alternative to hospitalization to manage the care of oxygen dependent pediatric recipients. Home pulse oximetry is covered when used to monitor oxygen saturation in order to determine appropriate supplemental oxygen levels. Home pulse oximetry is not covered for the purpose of qualifying or requalifying a patient for home oxygen.

(1) All oximeters approved for coverage must have printing capabilities that document an adequate number of sampling hours, per cent of oxygen saturation and an aggregate of the results.

(2) The oximeter must be preset, self-sealed and not adjustable by the consumer or anyone in the home.

(3) All oximeter printouts must be reliable, legible and maintained in the consumer's medical record.

(4) The consumer and/or the consumer's caregiver must be trained in the proper use of the pulse oximeter, the proper recording of measurements, and in whatever action is necessary to reverse a low oxygen saturation level. Documentation of this training must be kept in the provider's files.

(B) The following methods of home pulse oximetry services are covered:

(1) "Diagnostic monitoring," which is defined as monitoring for periods of up to twenty-four hours in length. Coverage is limited to a maximum of four monitoring periods per month. Prior authorization is required for diagnostic monitoring.

(2) "Continuous monitoring," which is defined as twenty-four-hour monitoring, seven days a week. Prior authorization is required for rental or purchase of an oximeter for use in continuous monitoring and may be requested for three months at a time when equipment is rented.

(C) All prior authorization requests must include a fully completed JFS 03401 (rev. 6/2006) "Certificate of Medical Necessity/Prescription Pulse Oximeter"(CMN) (appendix A to this rule) that is signed by an eligible prescriber and dated no more than thirty days prior to the first date of service. Additionally, the following criteria and documentation requirements must be met to establish medical necessity:

(1) Diagnostic monitoring.

(a) Diagnostic monitoring may be approved for payment to assess oxygen saturation:

(i) When a consumer is weaning from oxygen and/or prior to weaning; or

(ii) On a periodic basis for oxygen dependent, clinically unstable consumers.

(b) Prior authorization requests must include legible oximeter printouts of any prior oximeter monitoring and documentation of the resulting impact on the management of the consumer's care.

(c) Diagnostic monitoring may be considered for authorization when provided to a consumer in response to a significant clinical event or exacerbation of clinical status that results in a critical change in oxygen saturation or that requires diagnostic monitoring in order to assess oxygen saturation. Since oximeter monitoring under these circumstances must be provided immediately after the clinical event in order to assure timely assessment of oxygen requirements, authorization for payment will only be considered after the service has been provided.

(2) Continuous monitoring.

Continuous oximeter monitoring in the home may be appropriate in the management of pediatric consumers with prolonged oxygen dependency who are at risk of a critical fluctuation in oxygen saturation. Requests for prior authorization of continuous home oximeter monitoring will include documentation by the managing prescriber that the consumer is clinically unstable with chronically compromised respiration and frequently varying oxygen requirements, at risk for critical fluctuations in oxygen saturation, and experiencing one or more of the following:

(a) Frequent bradycardia;

(b) Frequent oxygen desaturation;

(c) Chronic lung disease;

(d) Ventilator dependent;

(e) Poor growth and development and suspect for inadequate oxygenation; or

(f) Other risk factors that may result in sudden, critical fluctuations in oxygen saturation (hyperoxia, hypoxia).

(D) Rental payments will be made for oximeters used for diagnostic and continuous monitoring. Oximeters will be considered for purchase when continuous monitoring is authorized for periods in excess of ten months; subsequent monthly rental payments, less the cost of the probes, will be applied to the purchase price. The monthly rental payment amount includes reimbursement for:

(1) Set up and instructions;

(2) Maintenance and repair;

(3) Emergency service visits or other interim visits;

(4) Supplies and accessories (cable, printer/printer tape, carrying case, etc.); and

(5) Permanent, reusable, or disposable probes (transducers) and probe wraps or tape.

(E) Oximeter probes may be purchased when prior authorized for use in conjunction with continuous monitoring when a monitor is purchased by the Ohio department of job and family services (ODJFS) and when a monitor is owned by the consumer, if continuous monitoring has been determined to be medically necessary in accordance with this rule. Oximeter probes must be billed using the code codes established for that purpose and listed in appendix A to rule 5101:3-10-03 of the Administrative Code.

Appendix Certificate of Medical Necessity/Prescription Pulse Oximeter

See Form at

http://www.registerofohio.state.oh.us/pdfs/5101/3/10/5101$3-10-23_PH_FF_A_APP1_20070330_1019.pdf

Effective: 04/16/2007
R.C. 119.032 review dates: 11/16/2006 and 04/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 7/1/93