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Noninvasive pulse oximetry measures oxygen saturation using a probe. Oxygen saturation is determined by measuring the light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Exclusions

Noninvasive pulse oximetry is covered when it is medically necessary to evaluate conditions commonly associated with oxygen desaturation.

Continuous overnight pulse oximetry is covered when a beneficiary would otherwise require hospitalization solely for continuous overnight monitoring. The oximeter must be preset, self sealed, and not adjustable by the beneficiary or anyone in the home.

The device must provide a printout that documents an adequate number of sampling hours, percentage of oxygen saturation, and an aggregate of the results.

The results of the test must be reliable and maintained in the medical record. Medicaid shall not cover routine testing (in the absence of signs or symptoms suggestive of desaturation)

Place of Service

No prior approval is required under this policy for noninvasive pulse oximetry; this applies to the target service as a type of noninvasive pulse oximetry.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-3
• Records Management and Documentation Manual

Noninvasive pulse oximetry measures oxygen saturation using a probe. Oxygen saturation is determined by measuring the light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Exclusions

Noninvasive pulse oximetry is covered when it is medically necessary to evaluate conditions commonly associated with oxygen desaturation.

Continuous overnight pulse oximetry is covered when a beneficiary would otherwise require hospitalization solely for continuous overnight monitoring. The oximeter must be preset, self sealed, and not adjustable by the beneficiary or anyone in the home.

The device must provide a printout that documents an adequate number of sampling hours, percentage of oxygen saturation, and an aggregate of the results.

The results of the test must be reliable and maintained in the medical record. Medicaid shall not cover routine testing (in the absence of signs or symptoms suggestive of desaturation)

Place of Service

No prior approval is required under this policy for noninvasive pulse oximetry; this applies to the target service as a type of noninvasive pulse oximetry.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-3
• Records Management and Documentation Manual

Noninvasive pulse oximetry measures oxygen saturation using a probe. Oxygen saturation is determined by measuring the light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Exclusions

Noninvasive pulse oximetry is covered when it is medically necessary to evaluate conditions commonly associated with oxygen desaturation.

Continuous overnight pulse oximetry is covered when a beneficiary would otherwise require hospitalization solely for continuous overnight monitoring. The oximeter must be preset, self sealed, and not adjustable by the beneficiary or anyone in the home.

The device must provide a printout that documents an adequate number of sampling hours, percentage of oxygen saturation, and an aggregate of the results.

The results of the test must be reliable and maintained in the medical record. Medicaid shall not cover routine testing (in the absence of signs or symptoms suggestive of desaturation)

Place of Service

No prior approval is required under this policy for noninvasive pulse oximetry; this applies to the target service as a type of noninvasive pulse oximetry.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-3
• Records Management and Documentation Manual

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

The term “allergy” indicates an abnormally hypersensitive immune reaction in response to exposure to certain foreign substances. Allergy-producing substances are called "allergens.” When an allergic individual comes in contact with an allergen, the immune system mounts a response through the immunoglobulin E ( IgE ) antibody.

Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as by localized reactions in any organ system of the body. The reaction may be acute, subacute, or chronic, immediate, or delayed and may be caused by numerous offending agents including pollen, molds, foods, and drugs.

The management of an allergy or hypersensitivity may include identifying the offending substance (allergen) by means of various testing methods. Immunoglobulin E (IgE)-mediated allergy testing is evaluated by measuring allergen-specific IgE. This can be done through skin testing (in vivo) testing or with serological tests (in vitro). Allergy testing includes the performance, evaluation, and reading of the tests.

It is important to note that skin prick tests, and tests that measure total serum levels of IgE or allergen-specific IgE, only detect the presence of allergic sensitization. They do not, by themselves, make a diagnosis of allergy. For instance, almost one-half of the U.S. population has detectable allergen-specific IgE against a food allergen, but the overall prevalence of clinical food allergy is only about 4 to 6 percent.

Treatment options for allergies are avoidance of allergen, pharmacological therapy, and immunotherapy.

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Unit Value

Each antigen tested (one test) must be billed as one unit, even if more than one injection or scratch or prick of the antigen is used on the same day.

Limits

Specific IgE tests may be performed by a clinical laboratory.

Length of Stay

80 units per 365 calendar day

Exclusions

The policy also excludes investigational allergy tests, specifically leukocyte histamine release, Rebuck skin window, Prausnitz-Kustner test, cytotoxic food testing, conjunctival challenge testing, nasal challenge test, kinesiology testing, provocation-neutralization testing, and electrodermal testing.

Diagnosis Requirements

Specific IgE in vitro testing is covered only after the general allergy testing criteria are met. Services must be provided by a physician or qualified non-physician practitioner after completing a medical and immunologic history and physical exam. Based on that evaluation, the practitioner must determine that signs and symptoms are suggestive of an allergy or that the diagnosis indicates an allergy, such as asthma. The practitioner must establish a reasonable probability of exposure in the beneficiary's environment, document that symptoms are not controllable by empiric conservative therapy, document all tried and failed allergy treatments, select the appropriate allergy test with proven efficacy published in peer-reviewed literature, and order the test based on findings that document and appropriately support the antigen being used for testing. Specific IgE in vitro tests are covered for inhalant allergens including pollens, molds, dust mites, and animal dander, as well as foods, insect stings, and drugs. Policy-wide, the service must also be medically necessary, individualized, specific, and consistent with the beneficiary's symptoms or confirmed diagnosis, safely furnished, and not primarily for convenience.

Place of Service

Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

• 1N-1, Allergy Testing
• Records Management and Documentation Manual

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

N/A - No authorization is required