BlueCross and BlueShield of Montana Medical Policy/Codes
Home Apnea Monitor
Chapter: Durable Medical Equipment
Current Effective Date: December 27, 2013
Original Effective Date: February 26, 2009
Publish Date: December 27, 2013
Revised Dates: August 15, 2011; June 27, 2012; December 11, 2013
Description

Home apnea monitors generally monitor respiratory effort and heart rate and are typically utilized to monitor central apnea of prematurity in newly discharged at-risk or high-risk premature infants (infants are at increased risk of cardiorespiratory events until 43 weeks’ post-gestational age). An alarm will sound if there is respiratory cessation (central apnea) beyond a predetermined time limit (e.g., 20 seconds) or if the heart rate falls below a preset rate (bradycardia) to notify the parent that intervention (stimulation, mouth-to-mouth resuscitation, cardiac compressions) is required. Unless an oximeter is added to the 2-channel devices, home apnea monitors are not effective at detecting obstructive sleep apneas. False alarms due to movement artifact are common with pulse oximeters, and these devices are not intended for the diagnosis of sleep-disordered breathing in a child.

Sudden infant death syndrome (SIDS) refers to the sudden death of an infant younger than 1 year of age; the circumstances are unexplained after a thorough investigation that includes autopsy, examination of the death scene, and review of the family history. As a means to decrease the incidence of SIDS, in the 1970s, cardiorespiratory monitoring was suggested. However over time, scientific medical studies have failed to establish that the use of home monitoring reduces the incidence of SIDS. The American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome in 2005, reiterates the recommendations of previous policy statements that home monitoring should not be used to reduce the incidence of SIDS. (1,2) The AAP further recommends that proven practices should be promoted to reduce the incidence of SIDS, which include supine sleeping, avoidance of pre-and post-natal exposure to cigarette smoking, and a safe environment. The “Back to Sleep” Campaign was initiated in 1994 by the National Institute of Child Health and Development (NICHD), Maternal Child Health Bureau of Human Resources and Services Administration, AAP and organizations concerned about SIDS; this campaign is a national process to educate healthcare professionals, parents, and caregivers about the significance of placing infants in the supine sleeping position to reduce SIDS. (3) Since that time, the incidence of SIDS has declined dramatically. This has in turn led to an overall decrease in utilization of home apnea monitors.

Regulatory Status

A number of infant apnea monitors have been cleared for marketing by the U.S. Food and Drug Administration (FDA). One device is the SmartMonitor 2 Apnea Monitor (Philip Children’s Medical Ventures, Respironics), which was cleared for marketing through the 510(k) process in October 2003. The intended use is for continuous monitoring of respiration, heart rate, and SpO2 (pulse oximetry) of infant patients in a hospital or home environment.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Home apnea (i.e., cardiorespiratory) monitoring may be considered medically necessary for premature infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia, for up to three months after hospital discharge, or after the cessation of serious episodes for 14 consecutive days, whichever comes last.

Home cardiorespiratory monitoring (pneumogram) may be considered medically necessary in infants younger than 12 months of age in the following situations:

  • Those who have experienced an apparent life-threatening event; OR
  • Those with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise; OR
  • Those with neurologic or metabolic disorders affecting respiratory control, including central sleep apnea; OR
  • Those with chronic lung disease (i.e., bronchopulmonary dysplasia), particularly those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation.

NOTE: Home cardiorespiratory monitors should be equipped with an event recorder whenever possible. The physician should perform monthly review and provide medical necessity for continuing monitoring.

Home cardiorespiratory monitoring (pneumogram) is considered not medically necessary when prescribed to prevent sudden infant death syndrome (SIDS), or for infants with any siblings with a history of SIDS, but without at least one of the indications cited above.

Home cardiorespiratory monitoring (pneumogram) in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, is considered experimental, investigational and unproven.

A back-up electrical system and/or alterations to the living quarters required for the monitor are considered not medically necessary as they are considered to be convenience.

The following services are considered part of the rental/purchase fee for the monitor:

  • Retrieval of recorded data from the monitor event recorder,
  • Parental training sessions (e.g., cardiopulmonary resuscitation [CPR] classes and/or instructions on monitor use).

 
Rationale

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)

Summary

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.”

Coding

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.

ICD-9 Codes
770.7, 770.81-770.89
ICD-10 Codes

P22.0, P22.1, P22.8, P22.9, P24.81, P27.1, P27.8, P28.2, P28.3-P28.4, P28.5, P28.81, P28.89, P28.9, P84, R68.13, Z93.0

Procedural Codes: 94774, 94775, 94776, 94777, A4556, A4557, E0618, E0619
References
  1. American Academy of Pediatrics. Committee on Fetus and Newborn. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics 2003; 111(4 pt 1):914-7.
  2. American Academy of Pediatrics. Task Force on Sudden Infant Death Syndrome. Diagnostic coding shifts, controversies regarding the sleep environment, and new variables to consider in reducing risk. Pediatrics 2005; 116(5):1245-55.
  3. National Institute of Child Health and Human Development. Back to Sleep Campaign. Available online at: http://www.nichd.nih.gov Last accessed February 2012.
  4. American Academy of Pediatrics. Reaffirmed and retired policy. Pediatrics 2007; 120(3):683-4. Available online at: http://aappolicy.aappublications.org Last accessed February 2012.
  5. Strehle EM, Gray WK, Gopisetti S et al. Can home monitoring reduce mortality in infants at increased risk of sudden infant death syndrome: a systematic review. Acta Paediatr 2012; 101(1):8-13.
  6. Halbower AC. Pediatric home apnea monitors: coding, billing, and updated prescribing information for practice management. Chest 2008; 134(2):425-9.
  7. Home Apnea Monitoring. Chicago, Illinois: Blue Cross Blue Shield Association. (March 2012) Durable Medical Equipment 1.01.06.
History
August 2011 Policy reviewed: updated description, rationale, and references. No policy statement change
June 2012 Policy updated with literature review through January 2012. Reference 5 added; other references renumbered or removed. Policy statements unchanged.
December 2013 Policy formatting and language revised.  Removed CPT code 94772.  Added the following medically necessary statement: "Home apnea (i.e., cardiorespiratory) monitoring may be considered medically necessary for premature infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia, for up to three months after hospital discharge, or after the cessation of serious episodes for 14 consecutive days, whichever comes last".
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Home Apnea Monitor