Long recognized as a clinical problem in infants, apnea has been the subject of considerable investigative and clinical attention. Although progress has been made and certain categories of apnea have been delineated, etiology remains unclear in many situations. Furthermore, the condition is common in certain populations, such as premature infants. Whether an apneic event occurs independently, in association with a pathophysiologic process such as sepsis, or because of an environmental factor such as change in temperature, the possible adverse effects of interrupted breathing are concerning. In deciding whether or not to monitor for apnea, the primary objective is to serve the best interest of the infant, and the decision should primarily be based on that infant’s history and individual medical situation.
Sudden Infant Death Syndrome (SIDS)
A policy statement from the American Academy of Pediatrics (AAP; reaffirmed in 2007) does not recommend apnea monitoring in sudden infant death syndrome (SIDS) siblings, noting that the theory that apneic episodes are related to SIDS has never been proven in spite of extensive research over several decades. (4) In addition, epidemiologic studies have failed to document any impact of home cardiorespiratory monitoring for apnea and/or bradycardia on the incidence of SIDS. Moreover, the AAP document noted that there is no evidence that the presence of apnea and/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 statement concluded “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 – supine sleep position, safe sleeping environments, and elimination of prenatal and postnatal exposure to tobacco smoke. Parents should also be advised that home cardiorespiratory monitoring has not been proven to prevent sudden unexpected deaths in infants.”
In 2012, Strehle and colleagues published a systematic review of literature on the impact of home monitoring (apnea monitoring, respiratory monitoring or cardiorespiratory monitoring) on mortality in infants at increased risk of SIDS. (5) The review identified 1 pilot study to assess the feasibility of a randomized controlled trial (RCT) evaluating home monitoring and 10 unique case series. The authors concluded that there is a lack of high-level evidence that home monitoring is beneficial in preventing SIDS.
A 2008 review by Halbower of coding, billing, and prescribing information for pediatric home apnea monitors (6) noted that during the 30-year period when home cardiorespiratory monitors were used (prior to AAP safe sleep recommendations), the occurrence of SIDS was not reduced.
Other Respiratory Conditions
There is a lack of evidence for use of home apnea monitors in other conditions. For many of these conditions, trials would be difficult to perform due to small numbers of patients and logistic difficulties for these conditions that make enrollment in trials difficult. As a result, the best available recommendations for treatment currently rely on expert consensus.
A consensus document released by the AAP, last updated in 2007, addresses the use of home apnea monitors for other respiratory conditions. (4) The AAP policy statement 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 who have:
- experienced an apparent life-threatening event;
- tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise;
- neurologic or metabolic disorders affecting respiratory control; or
- chronic lung disease (i.e., bronchopulmonary dysplasia), particularly those requiring supplemental oxygen; continuous positive airway pressure; or mechanical ventilation.
A 2008 review by Halbower of coding, billing, and prescribing information for pediatric home apnea monitors indicated that evidence remains limited regarding whether home apnea monitors improve health outcomes in comparison with the unmonitored infant. (6)
There is insufficient evidence from published studies and a lack of support from national guidelines for home apnea monitoring to prevent SIDS. For other respiratory conditions, there is also a lack of published evidence; however, national guidelines published by the AAP have identified specific groups of infants who might benefit from home monitoring because of other factors that increase the risk of sudden death (e.g., tracheostomies, chronic lung disease, etc.). These conditions identified by the AAP as benefiting from home apnea monitor may therefore be considered medically necessary.
Practice Guidelines and Position Statements
The American Academy of Pediatrics re-affirmed their 2003 policy on home apnea monitoring in 2007. (1, 4) The document noted that infants who may benefit from home monitoring include those who have experienced an apparent life-threatening event, have tracheostomies, have anatomic abnormalities that make them vulnerable to airway compromise, or have neurologic or metabolic disorders affecting respiratory control, including central sleep apnea, chronic lung disease including bronchopulmonary dysplasia and especially those individuals requiring supplemental oxygen, continuous positive airway pressure or mechanical ventilation. Furthermore, the AAP recommended that “if monitoring is to be used at home, parents and other caregivers must be trained in observation techniques, operation of the monitor, and infant cardiopulmonary resuscitation. Medical and technical support staff should always be available for direct or telephone consultation.”
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.