Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-DME-08 Infant Home Apnea Monitors Form


Home cardiorespiratory (apnea) monitoring

Notes: Note: The duration of coverage for medically necessary criteria includes specifications such as until event free for 2 to 3 months if monitored due to BRUE, up to 43 weeks postmenstrual age or event free for 2 weeks (whichever comes later) for apnea of prematurity, up to one month post diagnosis for pertussis, and until event free for 6 weeks for GERD.

Indications

(904395) Has the infant experienced a brief resolved unexplained event (BRUE)? 
(904396) Does the patient have tracheostomies or anatomic abnormalities of the face, tongue, jaw, or airway? 
(904397) Does the patient have neurologic or metabolic disorders affecting respiratory control? 
(904398) Does the patient have chronic lung disease and require supplemental oxygen, continuous positive airway pressure, or mechanical ventilation? 
(904399) Does the infant diagnosed with apnea of prematurity have sudden cessation of breathing for at least 20 seconds, or accompanied by bradycardia or O2 desaturation, with early home discharge prior to term (38 weeks postmenstrual age)? 

YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



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).

Clinical Indications

Medically Necessary:

Home cardiorespiratory (that is, apnea) monitoring is considered medically necessary in any of the following infants:

  1. Those who have experienced a brief resolved unexplained event (BRUE). If monitored due to BRUE, use of an apnea monitor is considered medically necessary until event free for 2 to 3 months.
  2. Those with tracheostomies or anatomic abnormalities of the face, tongue, jaw or airway that make them vulnerable to airway compromise.*
  3. Those with neurologic or metabolic disorders affecting respiratory control.*
  4. Those with chronic lung disease (such as, bronchopulmonary dysplasia), particularly those requiring supplemental oxygen; continuous positive airway pressure; or mechanical ventilation.*
  5. Those with apnea of prematurity, defined as sudden cessation of breathing that lasts for at least 20 seconds or is accompanied by bradycardia (heart rate less than 80 beats per minute) or oxygen (O2) desaturation (O2 saturation less than 90% or cyanosis) in an infant with early home discharge prior to term (38 weeks). Continued use is considered medically necessary up to 43 weeks postmenstrual age or event free for 2 weeks, whichever comes later.
  6. Those discharged home on a schedule of weaning narcotics.*
  7. Those with bradycardia on caffeine, theophylline, or similar agents, until event free for 2 weeks off medication.
  8. Those with diagnosis of pertussis, with positive cultures. If monitored for pertussis, use of a monitor is considered medically necessary for up to one month post diagnosis.
  9. Those with diagnosis of gastroesophageal reflux disease (GERD) that results in apnea (at least 20 seconds), bradycardia (heart rate less than 80 beats per minute), or oxygen desaturation (O2 saturation less than 90% or cyanosis), until event free for 6 weeks.

*Note: See Duration section below.

Other considerations:

  1. The home monitor should be equipped with an event recorder.
  2. The physician should establish a specific plan for periodic review and termination of the home monitor before initiating therapy.

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.

Duration

Duration:

  • Infant apnea monitors are usually considered medically necessary for approximately 3 months except for specific conditions listed above.
  • Continued use of an apnea monitor is considered medically necessary, even when infants become 12 months old during the course of a specified medically necessary duration of use.
  • Apnea monitoring beyond 12 months old requires physician documentation supporting the continuation of monitoring.