Clinical UM Guideline
|Subject:||Infant Home Apnea Monitors|
|Guideline #:||CG-DME-08||Current Effective Date:||10/06/2015|
|Status:||Revisd||Last Review Date:||08/06/2015|
This document addresses the use of apnea (cardiorespiratory) monitors for use in the home to monitor both respiratory and heart rates on infants. An alarm will sound if there is respiratory cessation (apnea) beyond a predetermined time limit (for example, 20 seconds), or if the heart rate falls below a preset rate (bradycardia).
Home cardiorespiratory (that is, apnea) monitoring is considered medically necessary in any of the following infants:
*Note: See Duration section below.
Note: Short-term monitoring to assist the family transition to home may be indicated in some cases following a previous sibling death from sudden infant death syndrome (SIDS) or following a particularly complex and protracted neonatal hospital course.
Not Medically Necessary:
Home apnea monitoring is considered not medically necessary for infants who do not meet the medically necessary criteria listed above.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|94774||Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, review, interpretation, and preparation of a report by a physician or other qualified healthcare professional|
|94775||Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitor attachment only (includes hook-up, initiation of recording and disconnection)|
|94776||Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitoring, download of information, receipt of transmission(s) and analyses by computer only|
|94777||Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; physician, interpretation and preparation of report only by a physician or other qualified healthcare professional|
|E0618||Apnea monitor, without recording feature|
|E0619||Apnea monitor, with recording feature|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
Infant home apnea monitors were designed with the purpose of protecting infants by identifying central apnea or bradycardia and signaling for parental intervention to prevent death (Halbower, 2008). Data recording devices are used with the monitor so the health care provider can study the event. The U.S. Food and Drug Administration (FDA, 2002) 510K premarket review process for class II devices defines apnea monitors as:
A complete system intended to alarm primarily upon the cessation of breathing timed from the last detected breath. The apnea monitor also includes indirect methods of apnea detection, such as monitoring of heart rate and other physiological parameters linked to the presence or absence of adequate respiration.
The American Academy of Pediatrics (AAP) 2003 policy statement regarding apnea, SIDS, and home cardiorespiratory monitoring (i.e., apnea monitoring) does not recommend apnea monitoring to prevent SIDS, noting the theory that apneic episodes related to SIDS have never been proven in spite of extensive research over several decades. The AAP also notes there is no evidence to demonstrate that the presence of apnea or bradycardia can identify a group at increased risk of SIDS; that home monitoring can provide warning in time for intervention to prevent sudden death; or that intervention would be successful in preventing unexpected death. The policy concludes: "Given the lack of evidence that home cardiorespiratory monitoring has any impact on SIDS, prevention of SIDS is not an acceptable indication for home cardiorespiratory monitoring." The AAP recommends that pediatricians should promote proven practices that decrease the risk of SIDS such as supine sleep position, safe sleeping environments, and elimination of prenatal and postnatal exposure to tobacco smoke. Parents should be advised that home cardiorespiratory monitoring has not been proven to prevent sudden unexpected deaths in infants.
The AAP policy statement was reaffirmed in 2005, and also identified infants who could benefit from home monitoring, not because of an increased risk of SIDS, but because of other factors that increase the risk of sudden death. These infants include those that have:
In the 2011 update of expanded recommendations for apnea monitors as a strategy to reduce SIDS, the AAP policy notes, "There is no evidence that use of such devices decreases the incidence of SIDS. They might be of value for selected infants but should not be used routinely."
It is recognized that the later sibling(s) of an infant who died of SIDS presents a unique emotional and clinical dilemma. Many clinicians suggest monitoring such infants until they are 1 month older than the age at which the sibling died, and remain event free. Although such use is not directly supported by specific evidence in the peer reviewed medical literature, it may be impossible to preclude monitoring if one or more siblings has died of SIDS. Short-term monitoring to assist the family transition to home may be indicated in some cases following a previous sibling death from SIDS or following a particularly complex and protracted neonatal hospital course.
Types of Apnea
There are three types of infantile apnea: central, obstructive, and mixed.
Central Apnea: Central apnea is characterized by complete cessation of respiratory efforts on the monitor and is usually related to central nervous system injury, very premature infants in whom the respiratory center in the brain is immature, depressant medications (for example, narcotics, sedatives), or metabolic conditions (for example, hypoglycemia). The chest is still and no air passes through the nose or mouth.
Obstructive Apnea: A common type of apnea in children, obstructive apnea is caused by an obstruction of the airway (such as enlarged tonsils and adenoids) and is most likely to happen during sleep when the soft tissue at back of the throat is most relaxed. In obstructive apnea, there is no airflow below the glottis though the monitor will continue to demonstrate breathing movements. The chest is moving, but no air passes through the nose or mouth. Infant home monitoring may identify heart rate changes that can accompany episodes of obstructive apnea.
Mixed Apnea: Mixed apnea is a combination of central and obstructive apnea and is seen particularly in infants or young children who have abnormal control of breathing. Mixed apnea may occur when a child is awake or asleep.
Monitors that are equipped with an event recorder are able to capture and store data surrounding significant events, such as heart rate and rhythm, for later analysis by a physician. If home cardiorespiratory monitoring is prescribed, the monitor should be equipped with an event recorder. Information from the monitor can be used to distinguish the type of apnea and allow for a distinct treatment plan based on the etiology.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Apparent Life Threatening Event (ALTE)
Home Cardiorespiratory Monitor
Infant Home Apnea Monitors
Sudden Infant Death Syndrome
|Revised||08/06/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Clarified criteria- spelled out abbreviation "i.e." Updated Discussion and References sections.|
|Reviewed||08/08/2013||MPTAC review. Added Web Site section.|
|Reviewed||08/09/2012||MPTAC review. Updated Discussion and References.|
|Reviewed||08/18/2011||MPTAC review. Updated Coding, Discussion and References.|
|Reviewed||08/19/2010||MPTAC review. Discussion and references updated.|
|Reviewed||08/27/2009||MPTAC review. Discussion and references updated. Place of service section deleted. Coding section updated with 10/01/2009 ICD-9 changes.|
|Reviewed||08/28/2008||MPTAC review. Description, discussion, and references updated.|
|Revised||08/23/2007||MPTAC review. Clarified continued use of monitor for apnea of prematurity. Clarified Not Medically Necessary statement. References updated.|
|01/01/2007||Updated coding section with 01/01/2007 CPT/HCPCS changes.|
|Reviewed||09/14/2006||MPTAC review. References and coding updated.|
|Revised||09/22/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
Last Review Date
|Memo 102 Coverage Guidelines (S.E. Region)||Sudden Infant Death Syndrome (SIDS) Monitors|
|WellPoint Health Networks, Inc.|
|Clinical Guideline||Infant Home Apnea Monitor|