Aetna considers apnea monitors medically necessary durable medical equipment (DME) for infants less than 12 months of age with documented apnea or who have known risk factors for life threatening apnea according to the following indications:
Aetna considers infant apnea monitors experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.
Aetna considers the use of remote infrared sensor for the detection of infant sleep apnea experimental and investigational because its effectiveness for has not been established.
* Except as specified for certain indications noted above, infant apnea monitors are usually considered medically necessary for approximately 3 months. Continued use of an apnea monitor is considered medically necessary for the durations noted in this policy, even when infants reach 12 months of age during the course of specified medically necessary duration of use. Apnea monitoring for children beyond 12 months old requires physician documentation supporting the continuation of monitoring (e.g., continued alarms, documented apnea, bradycardia, or hemoglobin desaturation).
The later siblings of infants who died of SIDS present 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. Aetna considers apnea monitors medically necessary in such circumstances.
The term “post-conceptional age” is defined as gestational age at birth plus age in weeks from birth. According to the American Academy of Pediatrics, this is more accurately designated as “postmenstrual age”.
Types of Monitors/Studies:
Because of the capabilities of a smart monitor, continuing sleep studies and pneumograms are not typically necessary. Should the ordering doctor wish to continue obtaining pneumograms for a child on a smart monitor, Aetna will alert the ordering doctor that continued use of a smart monitor is not considered medically necessary. Aetna considers a regular apnea monitor medically necessary for the duration of time that the doctor continues to want ongoing studies.Background
This policy is supported by a statement by the American Academy of Pediatrics (2003) on home apnea monitoring of infants.
There are 3 types of infant apnea: (i) central, (ii) obstructive, and (iii) mixed central and obstructive apnea. In central or diaphragmatic apnea, the infant makes no effort to breathe; the chest is still, and no air passes through the mouth or nose. In obstructive apnea, the chest is moving but no air passes through the mouth or nose (usually due to soft tissue such as the tongue blocking the upper airway). In mixed apnea, the infant has episodes of both central and obstructive apnea all within the same event. Most home infant apnea monitors measure chest movements and heart rate. Normally, the monitor's alarm is set to go off if the infant stops breathing for 20 seconds or if the heart rate slows to less than 80 beats/min (Stehlin, 1991).
Bani Amer and colleagues (2010) presented a contactless method for monitoring infant sleep apnea. The method uses a remote infrared sensor to monitor the motion of the infant's abdomen. According to the developers, this method has potential important clinical advantages in comparison with conventional methods. First, it has the potential to improve the comfort and compliance of the infants. Second, it may eliminate the effects of motion artefacts and skin irritation. Third, it may enhance infant safety. Fourth, it does not require frequent calibration and thus enables a continuous monitoring of sleep apnea. Finally, it is suitable for home applications. Experimental evaluation of this method showed that it has 85 % accuracy, 85.71 % specificity and 84.62 % sensitivity, which imply that it is a promising technique for the detection of infant sleep apnea.
Silvestri et al (1994) examined children referred to their apnea program who were greater than or equal to 12 months of age, beyond the at-risk period for sudden infant death syndrome (SIDS), but for whom home cardiorespiratory monitoring had continued. The objectives of this study were to (i) determine reasons for initiation and continuation of monitoring, (ii) apply documented monitoring of transthoracic impedance, electrocardiographic signals, and, in a subset of patients, pulse oximetry, to determine the types of cardiorespiratory events that these children experienced, and (iii) describe how documented monitoring was applied for eventual discontinuation of monitoring. Among 45 patients (median age of 22 months), 263 disks were collected, representing 2,982 monitor days. Indications for initiation of monitoring included an apparent life-threatening event in 51.1 % of patients, apnea of prematurity in 35.5 %, history of SIDS or apparent life-threatening event in a relative in 9 %, and intra-uterine drug exposure in 4.4 %. Continuation of monitoring had been based on continued alarms and, in 31 % of patients, documented apnea, bradycardia, or hemoglobin desaturation. In 40 of 45 patients, 2,292 episodes of apnea (17.5 % of all events) were recorded (range of 16 to 31 seconds). Five patients had 223 episodes of bradycardia (1.7 % of all events). Of all 13,075 recorded events, 76.8 % resulted in audible alarms, but only 3.9 % of these alarms were for apnea and 2.2 % were for bradycardia. Of 19 patients studied with pulse oximetry, 18 had 663 episodes of hemoglobin desaturation less than 90 %. All children were thriving at the time of referral. Discontinuation of monitoring was based on a child's ability to resume breathing spontaneously or on normalization of heart rate or hemoglobin saturation before the audible alarm sounded, for a minimum of 2 to 3 months. By extension of the audible apnea alarm to 25 or 30 seconds, lowering of the cut-off point for bradycardia alarm, or lowering of the cut-off point for the oximetry alarm, a recommendation to discontinue monitoring could be made for 41 patients. Of these, no child had a recurrence of cardiorespiratory events or died of SIDS. Documented monitoring proved to be a useful clinical tool for investigation of the clinical and physiologic importance of these cardiorespiratory events in children beyond the at-risk period for SIDS; recommendations about discontinuation of monitoring could be made knowledgeably and safely.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes covered if selection criteria are met:|
|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, physician review, interpretation, and preparation of a report|
|94775||monitor attachment only (includes hook-up, initiation of recording and disconnection)|
|94776||monitoring, download of information, receipt of transmission(s) and analyses by computer only|
|94777||physician review, interpretation and preparation of report only|
|HCPCS codes covered if selection criteria are met:|
|A4556||Electrodes (e.g., apnea monitor), per pair|
|A4557||Lead wires (e.g., apnea monitor), per pair|
|E0618||Apnea monitor, without recording feature|
|E0619||Apnea monitor, with recording feature|
|Other HCPCS codes related to the CPB:|
|J0706||Injection, caffeine citrate, 5 mg|
|J2810||Injection, theophylline, per 40 mg|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|A37.00 - A37.91||Whooping cough|
|G93.1||Anoxic brain damage, not elsewhere classified|
|I49.5||Sick sinus syndrome|
|I49.8||Other specified cardiac arrhythmias|
|K21.9||Gastro-esophageal reflux disease without esophagitis|
|P07.00 - P07.18
P07.21 - P07.39
|Disorders of newborn related to short gestation and low birthweight, not elsewhere classified|
|P22.0 - P28.89||Respiratory disorders specific to the perinatal period|
|P84||Other problems with newborn|
|Q30.0 - Q34.9||Congenital malformations of the respiratory system|
|Q39.0 - Q39.9||Congenital malformations of esophagus|
|R06.81||Apnea, not elsewhere classified|
|Z99.11||Dependence on respirator [ventilator] status|
|Z99.81||Dependence on supplemental oxygen|