Clinical Requirements: Respiratory Therapy Equipment — Oximetry

(A) Requirements for Use. (1) Spot Checks. Spot checks are reimbursable when used to document the presence of hypoxemia and to quantitate the response of arterial oxyhemoglobin saturation to therapeutic intervention when hypoxemia is transient and unpredictable even in the presence of supplemental oxygen. (2) Continuous. Continuous oximetry is reimbursable when hypoxemia (SaO2 is less than 90% or decreases 5% from baseline) is transient, variable, and unpredictable, even in the presence of supplemental oxygen, and occurs frequently on a regular basis, so that it requires frequent changes in the supplemental oxygen in response to and to correct hypoxemic episodes. (B) Reasons for Noncoverage. If oximetry demonstrates hypoxemia that is correctable and stabilized with supplemental oxygen (that is, during sleep, exercise, or seizures) or some other therapeutic intervention, continued monitoring is not reimbursable. (C) Required Documentation. The provider must submit the following documentation for reimbursement for oximetry: (1) a written prescription pursuant to 130 CMR 427.408; (2) prior authorization pursuant to 130 CMR 427.409; and (3) documentation of the medical necessity for oximetry and that the test was performed and results documented under the conditions that the oximeter is requested through notation in the medical record and in the prior-authorization request of the results, therapeutic intervention, and clinical decisions based on SaO2 measurements (see 130 CMR 427.407(D) and 450.206).