BlueCross BlueShield of Tennessee Medical Policy Manual

Infant Home Apnea Monitoring

DESCRIPTION

Home apnea monitors generally monitor respiratory and heart rates in the home setting. An alarm will sound if there are no respirations (apnea) for more than a predetermined limit (e.g., 20 seconds) or if the heart rate falls below a certain predetermined limit (bradycardia). Documentation of the apnea events is obtained by downloading information from the monitor.

POLICY

• Infant home apnea monitors ordered by a physician are considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)

MEDICAL APPROPRIATENESS

• Infant home apnea monitoring for the treatment of clinically significant recurrent apnea is considered medically appropriate if ALL the following criteria are met:

  • Ordered by a physician
  • ANY ONE of the following:
    • Breathing stops for 20 seconds or longer
    • Breathing stops for less than 20 seconds and is associated with bradycardia or cyanosis
    • Siblings of sudden death syndrome (SID) victims
    • Siblings of those diagnosed as having clinically significant apnea

ADDITIONAL INFORMATION

Discontinuation of the home apnea monitor will be given consideration based on any of the following:

• Six or eight weeks without significant alarms (e.g., apnea lasting greater than or equal to 15 seconds) or clinical events (e.g., apnea event requiring intervention, not a false alarm)

• One or two immunizations and/or recovery from an upper respiratory infection without significant alarms

• No apparent life-threatening event (ALTE), within 2-3 months past the initial event and without significant alarms

• If infant is sibling of SIDS victim, monitoring can be discontinued one month past the age of death of sibling and/or at least 4-6 months adjusted age

• Non-compliance, to include but not limited to, the following:

• The monitor is not being used

• The caregiver does not keep sleep study or clinic appointments and caregiver has not been compliant with medical advice

SOURCES

American Academy of Pediatrics. (1998, August). Policy statement: Hospital discharge of the high-risk neonate -- proposed guidelines (RE9812). Retrieved August 3, 2001 from http://www.aap.org/policy/re9812.html.

American Academy of Pediatrics. (2000). Policy statement: Recommendations for preventive pediatric health care (RE 9939). Retrieved August 6, 2001 from http://www.aap.org/policy/re9939.html.

American Academy of Pediatrics. (2000, March). Policy statement: Changing concepts of sudden infant death syndrome: Implications for infant sleep environment and sleep position. Retrieved April 1, 2003 from http://aappolicy.aappublications.org/cgi/content/full/pediatrics;105/3/650?fulltext=SIDS&searchid=QID_NOT_SET.

American Academy of Pediatrics. (2003, April). Policy statement: Apnea, sudden infant death syndrome, and home monitoring. Retrieved February 7, 2007 from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;111/4/914.pdf

American Academy of Pediatrics. (2005, November). Policy statement: The changing concepts of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Retrieved February 7, 2007 from http://aappolicy.aappublications.org/cgi/reprint/pediatrics;116/5/1245.pdf.

BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2003). Home apnea monitors (1.01.06). Retrieved May 16, 2005 from BlueWeb.

National Institutes of Health. (1986, September-October). Infantile apnea and home monitoring. Retrieved January 26, 1999 from http://consensus.nih.gov/cons/cons.htm.

Ramanathan, R., Corwin, M. J., Hunt, C. E., Liser, G., Tinsley, L. R., Baird, T., et al. (2001). Cardiorespiratory events recorded on home monitors. Journal of the American Medical Association, 285 (17), 2199-2207.

Subhani, M., Katz, S., & DeCristofaro, J. D. (2000). Prediction of postdischarge complications by predischarge event recordings in infants with apnea of prematurity. Journal of Perinatology, 20 (2), 92-95. Abstract retrieved August 6, 2001 from PubMed database.

Tauman, R., & Sivan, Y. (2000). Duration of home monitoring for infants discharged with apnea of prematurity. Biology of the Neonate, 78 (3), 168-173. Abstract retrieved August 6, 2001 from PubMed database.

U. S. Food and Drug Administration. (2002, July). Center for Devices and Radiological Health. Class II special controls guidance document: Apnea monitors; guidance for industry and FDA. Retrieved March 31, 2003 from http://www.fda.gov/cdrh/ode/guidance/1178.html.

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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