Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 09102 | First Coast Service Options, Inc. | A and B MAC | FL |
| 09202 | First Coast Service Options, Inc. | A and B MAC | PR |
| 09302 | First Coast Service Options, Inc. | A and B MAC | VI |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57115 (Billing and Coding: Noninvasive Ear or Pulse Oximetry For Oxygen Saturation) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57115: Billing and Coding: Noninvasive Ear or Pulse Oximetry For Oxygen Saturation (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 107
- 2 groups
- Non-covered ICD-10-CM codes
- 1
- Procedure codes listed
- 3
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C34.00 | — |
| C34.01 | — |
| C34.02 | — |
| C34.10 | — |
| C34.11 | — |
| C34.12 | — |
| C34.2 | — |
| C34.30 | — |
| C34.31 | — |
| C34.32 | — |
| C34.80 | — |
| C34.81 | — |
| C34.82 | — |
| C34.90 | — |
| C34.91 | — |
| C34.92 | — |
| G47.30 | — |
| I01.8 | — |
| I09.81 | — |
| I11.0 | — |
| I13.0 | — |
| I13.2 | — |
| I16.0 | — |
| I16.1 | — |
Procedure codes: 94760, 94761, 94762.
Coverage indications, limitations and medical necessity
History/Background and/or General Information
Pulse oximetry provides a simple, accurate, and noninvasive technique for the continuous or intermittent monitoring of arterial oxygen saturation. A small lightweight device attaches to the finger or toe and directs through the nailbed two wavelengths of light; a photodetector measures absorption. Arterial pulsation is used to gate the signal to the arterial component of blood contained within the nailbed.
Ear oximetry is a noninvasive method for evaluating arterial oxygenation. Ear oximeters are commonly used in sleep studies.
Covered Indications
Single and Multiple Determinations of oxygen saturation:
Ear or pulse oximetry for oxygen saturation will be considered medically necessary when the patient has a condition resulting in hypoxemia and there is a need to assess the status of a chronic respiratory condition, supplemental oxygen requirements and/or a therapeutic regimen.
Continuous Overnight Monitoring of oxygen saturation:
Ear or pulse oximetry for oxygen saturation by continuous overnight monitoring will be considered medically necessary in the following circumstances:
• The patient must have a condition for which intermittent arterial blood gas sampling is likely to miss important variations, and
• The patient must have a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen.
Limitations
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual , Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2019-10-01
- Last reviewed by the contractor
- 2017-12-27
- MCD version
- 14
- Derived from
- L29236
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the First Coast Service Options, Inc. hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L33923 cover?
Pulse oximetry provides a simple, accurate, and noninvasive technique for the continuous or intermittent monitoring of arterial oxygen saturation. A small lightweight device attaches to the finger or toe and directs through the nailbed two wavelengths of light; a photodetector measures absorption. Arterial pulsation is used to gate the signal to the arterial component of blood contained within the nailbed. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33923 apply to?
First Coast Service Options, Inc. applies it to Medicare claims in FL, PR, VI. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33923?
The companion billing and coding article A57115 lists 107 ICD-10-CM codes in 2 groups that support medical necessity and 1 that do not; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33923?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.