Clinical Policy: NICU Apnea Bradycardia Guidelines Form

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Clinical Policy: NICU Apnea Bradycardia Guidelines Reference Number: CP.MP.82 Date of Last Revision: 01/24 Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description The purpose of this guideline is to assist with continuity of care, discharge planning, and the transition to outpatient and home care of infants affected by ongoing neonatal apnea and bradycardia events. It also serves as a guideline for the approval of continued stay for neonatal admissions. The recommendations below are based primarily on meta-analyses and practice patterns, as there are few random controlled trials in this area.

Guidelines Infants may be considered ready for discharge from inpatient care for cardiorespiratory events or caffeine administration when meeting the guidelines in I, as applicable.

Note: • Cardiorespiratory events associated with feeding are not uncommon in premature

infants due to incoordination of sucking, swallowing and breathing. The
significance of these events should be evaluated on an individual basis (e.g.,
severity of bradycardia, degree of desaturation, intervention(s) required, etc.).
Episodes associated with oral feedings may not be the same as episodes recorded
while sleeping. Parents should be instructed in the technique of identifying
feeding problems and correcting them.

• Caffeine has a relatively long half-life and levels may be therapeutic in preterm

infants for as long as seven days or more after discontinuation. It is appropriate to
observe an infant for seven days after the withdrawal of caffeine, but since the
discontinuation often occurs well before discharge, a “caffeine countdown”
should not typically prolong the date of discharge.1,2,3,5

• An assessment of cardiorespiratory stability in a car seat is recommended prior to

discharge for infants born at < 37 weeks gestation or with other risk factors for
respiratory compromise (e.g., neuromuscular, orthopedic problems).

• Parents or caregivers are encouraged to attend an infant CPR class and required to

complete CPR training as noted in I.A.3.d.

• Additional days may be needed for observation prior to discharge based on

gestational age at birth and recorded events.

Background Apnea of prematurity is a common condition of premature infants, often closely associated with bradycardia.1,6 The condition often results in prolonged lengths of stay in the neonatal intensive care units, as well as considerable parental anxiety. Each infant admitted to the neonatal intensive care unit (NICU) undergoes a unique hospital experience based upon their gestational age with discharge heavily dependent upon, at a minimum, the attainment of physiological maturity.7

The Committee on Fetus and Newborn has defined apnea of prematurity as a cessation of breathing that lasts for at least 20 seconds or is of shorter duration but accompanied by bradycardia, cyanosis or pallor in an infant younger than 37 weeks gestational age. Most cases are resolved by 37 weeks’ post-conceptional age; however, infants born at 24 to 28 weeks gestation frequently have apnea that persists longer, often to 44 weeks post-conceptional age.1

Episodes of bradycardia may be associated with oral feedings and also with apnea events that occur while sleeping.6 Bradycardia associated with feeding that resolves with interruption of Page 2 of 6

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CLINICAL POLICY NICU Apnea Bradycardia Discharge Guidelines

feeding is generally not regarded as a reason to delay discharge.4,8 Pathologic bradycardia (not associated with feeding) may be treated with pharmacologic or non-pharmacologic therapy. Non- pharmacologic measures include supplemental oxygen, artificial ventilation, and physical stimulation.5

Methylxanthine therapy, typically theophylline or caffeine, is the primary pharmacologic treatment for apnea of prematurity. Despite both agents having similar efficacy for decreasing episodes of apnea and bradycardia, results from a meta-analysis of five small trials of 108 infants noted considerably reduced adverse reactions with caffeine use versus theophylline use. Caffeine is recommended for infants with apnea of prematurity as an alternative to theophylline or supportive care alone.6 Caffeine citrate has a mean half-life of approximately 100 hours with some variation noted relative to gestational age at birth and chronological age.7 Because of its relatively long half-life in infants of < 33 weeks’ gestation, caffeine citrate has been ideal for once per day dosing in most infants. Also, because of the relatively large therapeutic index, the drug has been considered relatively safe. Maintenance dosing begins 24 hours after the loading dose at 5 to 10 mg/kg daily. Routine drug levels are not necessary unless there are signs of caffeine toxicity, such as tachycardia.6,9 Infants who fail to respond to caffeine therapy might require intubation, mechanical ventilation, or nasal intermittent positive pressure ventilation (NIPPV).6

Cardiorespiratory home monitoring is indicated when an infant has an ongoing medical condition that increases risk for apnea, airway obstruction, or hypoxemia. Such conditions include, but are not limited to, the following10: • Persistent apnea of prematurity or apnea of infancy • Chronic lung diseases (e.g., bronchopulmonary dysplasia), especially those requiring

supplemental oxygen, positive airway pressure, or mechanical ventilatory support

• Congenital myasthenic syndromes • Tracheostomy or other airway abnormalities.

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CLINICAL POLICY NICU Apnea Bradycardia Discharge Guidelines

Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions. Page 5 of 6

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CLINICAL POLICY NICU Apnea Bradycardia Discharge Guidelines

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Guidelines should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.

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