Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57205 (Billing and Coding: Oximetry Services) 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.
A57205: Billing and Coding: Oximetry Services (Billing and Coding, effective 2026-01-01)
- Covered ICD-10-CM codes
- 3158
- 2 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 3
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A15.0 | — |
| A15.5 | — |
| A15.8 | — |
| A15.9 | — |
| A20.2 | — |
| A21.2 | — |
| A22.1 | — |
| A37.01 | — |
| A37.11 | — |
| A37.81 | — |
| A37.91 | — |
| A42.0 | — |
| A43.0 | — |
| A48.1 | — |
| A70 | Chlamydia psittaci infections |
| B01.2 | — |
| B25.0 | — |
| B44.0 | — |
| B44.81 | — |
| B58.3 | — |
| B59 | Pneumocystosis |
| C33 | Malignant neoplasm of trachea |
| C34.00 | — |
| C34.01 | — |
Procedure codes: 94760, 94761, 94762.
Coverage indications, limitations and medical necessity
Notice: Compliance with the provisions in this policy may be monitored and addressed through post-payment data analysis and subsequent medical review audits.
History/Background and/or General Information
Oximetry measures oxygen saturation using a non-invasive probe. This is done by measuring light absorption of oxygenated hemoglobin and total hemoglobin in arterial blood.
Covered Indications
Medically necessary reasons for pulse oximetry include:
• Patient exhibits signs or symptoms of acute respiratory dysfunction such as:
• Tachypnea
• Dyspnea
• Cyanosis
• Respiratory distress
• Confusion
• Hypoxia
• Patient has chronic lung disease, severe cardiopulmonary disease or neuromuscular disease involving the muscles of respiration, and oximetry is needed for at least one of the following reasons:
• Initial evaluation to determine the severity of respiratory impairment
• Evaluation of an acute change in condition
• Evaluation of exercise tolerance in a patient with respiratory disease
• Evaluation to establish medical necessity of oxygen therapeutic regimen
• Patient has sustained severe multiple trauma or complains of acute severe chest pain
• Patient is under treatment with a medication with known pulmonary toxicity, and oximetry is medically necessary to monitor for potential adverse effects of therapy
• Overnight Oximetry is considered medically necessary when performed for any of the following circumstances:
• The patient has a condition for which intermittent arterial blood gas sampling is likely to miss important variations
• The patient has a condition resulting in hypoxemia and there is a need to assess supplemental oxygen requirements and/or a therapeutic regimen
Limitations
The following are considered not reasonable and necessary:
• Routine use of oximetry
• Results of tests performed by a durable medical equipment supplier to qualify patients for home oxygen service
Place of Services (POS)
These services may be performed in the home or office by a provider or by an independent diagnostic testing facility.
For additional information on services performed in an Independent Diagnostic Testing Facility (IDTF), please refer to Local Coverage Determination (LCD) L35448 Independent Diagnostic Testing Facility (IDTF) and Local Coverage Article: Billing and Coding: Independent Diagnostic Testing Facility (IDTF) A53252.
LCD Individual Consideration
Additional payment may be allowed for oximetric determinations exceeding the parameters described in the “Utilization Guidelines” section below on an “individual consideration” basis.
For frequency limitations please refer to the Utilization Guidelines section below.
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
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
- 2019-10-17
- Last reviewed by the contractor
- 2018-07-12
- MCD version
- 30
- Derived from
- L34749
The contractor lists one National Coverage Determination as related: NCD 240.2 Home Use of Oxygen. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
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 Novitas Solutions, Inc. hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L35434 cover?
Notice: Compliance with the provisions in this policy may be monitored and addressed through post-payment data analysis and subsequent medical review audits. 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 L35434 apply to?
Novitas Solutions, Inc. applies it to Medicare claims in AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX. 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 L35434?
The companion billing and coding article A57205 lists 3,158 ICD-10-CM codes in 2 groups that support medical necessity; 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 L35434?
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.