Close Window
Aetna Aetna
Clinical Policy Bulletin:
Apnea Monitors for Infants
Number: 0003


Policy

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:

  1. Diagnosis of pertussis, with positive cultures, upon discharge from acute care facility.  If monitored for pertussis, use of an apnea monitor is considered medically necessary for up to 1 month post diagnosis.
  2. Documented apnea accompanied by bradycardia to less than 80 beats per minute; use of an apnea monitor is considered medically necessary until the infant remains event free for 6 weeks. 
  3. Documented apnea accompanied by marked hypotonia; use of an apnea monitor is considered medically necessary until the infant remains event free for 6 weeks. 
  4. Documented apnea accompanied by oxygen desaturation (oxygen saturation below 90 %), cyanosis or pallor; use of an apnea monitor is considered medically necessary until the infant remains event free for 6 weeks.
  5. Documented gastro-esophageal reflux disease that results in apnea, bradycardia, or oxygen desaturation, until the infant remains event free for 6 weeks.
  6. Documented prolonged apnea of greater than 20 seconds in duration; use of an apnea monitor is considered medically necessary until the infant remains event free for 6 weeks.
  7. Infants with an apparent life-threatening event (ALTE), defined as an episode that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging.  If monitored due to ALTE, use of an apnea monitor is considered medically necessary until the baby remains event free for 6 weeks.
  8. Infants 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/min) or oxygen desaturation (oxygen saturation less than 90 % or cyanosis) in an infant younger than 37 weeks' gestational age.  Continued use is considered medically necessary until they are past a post-conceptional age of 43 weeks and are event free for 6 weeks.
  9. Infants with bradycardia on caffeine, theophylline, or similar agents, until event free for 6 weeks off medication.
  10. Infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation*.
  11. Infants with neurologic or metabolic disorders affecting respiratory control (medical necessity reviewed on an individual case basis)*.
  12. Infants with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise (medical necessity reviewed on an individual case basis)*.
  13. Later siblings of infants who died of sudden infant death syndrome (SIDS), use of an apnea monitor is considered medically necessary until the later siblings are 1 month older than the age at which the earlier sibling died and they remain event free.

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.

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.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
94774
94775
94776
94777
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 Injction, theophylline, per 40 mg
ICD-9 codes covered if selection criteria are met (not all-inclusive):
033.0 - 033.9 Whooping cough
348.1 Anoxic brain damage
427.81 Sinoatrial node dysfunction
427.89 Other specified cardiac dysrhythmia
530.81 Esophageal reflux
748.0 - 748.8 Congenital anomalies of respiratory system
750.3 Tracheoesophageal fistula, esophageal atresia and stenosis
750.4 Other specified anomalies of esophagus
765.00 - 765.09 Extreme immaturity
765.10 - 765.19 Other preterm infants
765.21 - 765.27 Weeks of gestation 24 or less completed
769 Respiratory distress syndrome
770.0 - 770.89 Other respiratory conditions of fetus and newborn
779.81 Neonatal bradycardia
782.5 Cyanosis
782.61 Pallor
786.03 Apnea
V44.0 Tracheostomy status
V46.1 Dependence on respirator
V46.2 Dependence on supplemental oxygen
Other ICD-9 codes related to the CPB [will be reviewed on an individual case basis]:
767.0 Subdural and cerebral hemorrhage
768.2 - 768.6 Fetal distress and birth asphyxia
772.10 - 772.14 Intraventricular hemorrhage
772.2 Subarachnoid hemorrhage
775.4 - 775.8 Metabolic disturbances specific to the fetus and newborn


The above policy is based on the following references:
  1. American Academy of Pediatrics, Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate -- proposed guidelines. Pediatrics. 1998;102(2 Pt 1):411-417.
  2. Corwin MJ, Lister G, Silvestri JM, et al. Agreement among raters in assessment of physiologic waveforms recorded by a cardiorespiratory monitor for home use. Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group. Pediatr Res. 1998;44(5):682-690.
  3. Steinschneider A, Richmond C, Ramaswamy V, Curns A. Clinical characteristics of an apparent life-threatening event (ALTE) and the subsequent occurrence of prolonged apnea or prolonged bradycardia. Clin Pediatr (Phila). 1998;37(4):223-229.
  4. Darnall RA, Kattwinkel J, Nattie C, Robinson M. Margin of safety for discharge after apnea in preterm infants. Pediatrics. 1997;100(5):795-801.
  5. Eichenwald EC, Aina A, Stark AR. Apnea frequently persists beyond term gestation in infants delivered at 24 to 28 weeks. Pediatrics. 1997;100(3 Pt 1):354-359.
  6. Malloy MH, Hoffman HJ. Home apnea monitoring and sudden infant death syndrome. Prev Med. 1996;25(6):645-649.
  7. Spinner S, Gibson E, Wrobel H, Spitzer AR. Recent advances in home infant apnea monitoring. Neonatal Netw. 1995;14(8):39-46.
  8. Malloy MH, Graubard B. Access to home apnea monitoring and its impact on rehospitalization among very-low-birth-weight infants. Arch Pediatr Adolesc Med. 1995;149(3):326-332.
  9. Keens TG, Ward SL. Apnea spells, sudden death, and the role of the apnea monitor. Pediatr Clin North Am. 1993;40(5):897-911.
  10. Carbone MT. Sudden infant death syndrome and subsequent siblings. N J Med. 1992;89(9):684-686.
  11. No authors listed. Infantile apnea and home monitoring. Natl Inst Health Consens Dev Conf Consens Statement. 1986;6(6):1-10.
  12. Kahn A, Blum D, Montauk L. Polysomnographic studies and home monitoring of siblings of SIDS victims and of infants with no family history of sudden infant death. Eur J Pediatr. 1986;145(5):351-356.
  13. Tudehope DI, Cleghorn G. Home monitoring for infants at risk of the sudden infant death syndrome. Aust Paediatr J. 1984;20(2):137-140.
  14. Duffty P, Bryan MH. Home apnea monitoring in 'near-miss' sudden infant death syndrome (SIDS) and in siblings of SIDS victims. Pediatrics. 1982;70(1):69-74.
  15. Aberdroth D, Moser DK, Dracup K, Doering LV. Do apnea monitors decrease emotional distress in parents of infants at high risk for cardiopulmonary arrest? J Pediatr Health Care. 1999;13(2):50-57.
  16. Cote A, Hum C, Brouillette RT, Themens M. Frequency and timing of recurrent events in infants using home cardiorespiratory monitors. J Pediatr. 1998;132(5):783-789.
  17. Baker L, Thyer B. Promoting parental compliance with home infant apnea monitor use. Behave Res Ther. 2000;38(3):285-296.
  18. Santin RL, Porat R. Apnea of prematurity. eMedicine Pediatrics Topic 1197. Omaha, NE: eMedicine.com; updated January 2, 2002.
  19. Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003;111(4 Pt 1):914-917.
  20. Bhatt-Mehta V, Schumacher RE. Treatment of apnea of prematurity. Paediatr Drugs. 2003;5(3):195-210.
  21. Poets CF. Apparent life-threatening events and sudden infant death on a monitor. Paediatr Respir Rev. 2004;5 Suppl A:S383-S386.
  22. Silvestri JM, Lister G, Corwin MJ, et al. Factors that influence use of a home cardiorespiratory monitor for infants: The collaborative home infant monitoring evaluation. Arch Pediatr Adolesc Med. 2005;159(1):18-24.
  23. Stehlin D. Infant apnea monitors help parents breathe easy. FDA Consumer. 1991;25(5).
  24. Eyssen M, Kohn L, Lambert ML, Van Den Steen D. Home monitoring of infants in prevention of sudden infant death syndrome. KCE Reports 46. Brussels, Belgium: Belgian Health Care Knowledge Centre (KCE); 2006.
  25. Naulaers G, Daniels H, Allegaert K, et al. Cardiorespiratory events recorded on home monitors: The effect of prematurity on later serious events. Acta Paediatr. 2007;96(2):195-198.
  26. Carbone T, McEntire B, Kissin D, et al. Absence of an increase in cardiorespiratory events after diphtheria-tetanus-acellular pertussis immunization in preterm infants: A randomized, multicenter study. Pediatrics. 2008;121(5):e1085-e1090.
  27. Halbower AC. Pediatric home apnea monitors: Coding, billing, and updated prescribing information for practice management. Chest. 2008;134(2):425-429.
  28. Silvestri JM. Indications for home apnea monitoring (or not). Clin Perinatol. 2009;36(1):87-99.
  29. Bani Amer MM, Az-Zaqah R, Aldofash AK, et al. Contactless method for detection of infant sleep apnoea. J Med Eng Technol. 2010;35(5-6):324-328.


email this page   


Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
Aetna
Back to top