BlueCross BlueShield of Tennessee Medical Policy Manual

Home Apnea Monitoring / Home Cardiorespiratory Monitoring

DESCRIPTION

Home apnea monitors (e.g. SmartMonitor 2) track respiratory effort and heart rate to detect episodes of apnea. They are used in the home environment for a variety of indications including but not limited to infants born prematurely, infants at increased risk of sudden infant death syndrome (SIDS), infants who have experienced a brief resolved unexplained event (previously known as apparent life-threatening event) which is characterized by cyanosis or pallor; absent, or markedly decreased breathing; marked change in tone; and/or altered level of responsiveness. An alarm on the home monitor system will sound if there is respiratory cessation (apnea) beyond a predetermined time limit (e.g., 20 seconds) or if the heart rate falls below a preset rate (bradycardia) to notify the parent or caregiver that intervention (stimulation, resuscitation, cardiac compressions) is required. All home monitors should have the capacity for event recording including respiratory rate, pattern and heart rate.

Home cardiorespiratory monitoring for apnea is generally not considered appropriate for pediatric patients older than 1 year of age. However, there may be a subset of young children who require cardiorespiratory monitoring beyond one year of age, such as certain patients with home noninvasive or invasive ventilator use or chronic lung disease.

Note: This policy applies only to the use of U.S. Food and Drug Administration approved home monitoring systems. A variety of commercially available baby monitoring devices are marketed to parents for monitoring infants’ sleep, breathing, and behavior. These devices are not sold as medical devices and are not considered durable medical equipment.

POLICY  

MEDICAL APPROPRIATENESS

IMPORTANT REMINDER

SOURCES

Agency for Healthcare Research and Quality (2015, July) NICU Family Information Packet, Appendix B: Clinical Materials to Share with Primary Care Providers. Retrieved December 12, 2016 from: http://www.ahrq.gov.

American Academy of Pediatrics (2016, May) Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Retrieved February 27, 2017 from: http://pediatrics.aappublications.org.

American Academy of Pediatrics. (2016, January). Apnea of prematurity. Retrieved February 18, 2016 from: http://pediatrics.aappublications.org.

American Academy of Pediatrics. (2016, November). SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Retrieved February 23, 2017 from: http://pediatrics.aappublications.org.

American Academy of Pediatrics. Committee on Fetus and Newborn. (2008). Hospital discharge of the high-risk neonate.  Retrieved February 16, 2016 from: http://pediatrics.aappublications.org.

American Academy of Pediatrics: Committee on Fetus and Newborn (2003, reaffirmed in 2008) Apnea, sudden infant death syndrome, and home monitoring. Retrieved February 27, 2017 from: http://pediatrics.aappublications.org.

Athanasakis, E., Karavasiliadou, S., and Styliadis, I. (2011) The factors contributing to the risk of sudden infant death syndrome. HIPPOKRATIA, 15, 2:127-31. (Level 1 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (3:2016). Home Cardiorespiratory Monitoring (1.01.06). Retrieved February 24, 2017 from BlueWeb. (16 articles and / or guidelines reviewed)

Bonafide, C., Jamison, D., and Foglia, E. (2017, January) The emerging market of smartphone-integrated infant psysiologic monitors. Journal of the American Medical Association (JAMA) Vol. 312, No. 4. 353-354. (Level 5 evidence)

National Institute of Health (2016) Ways to reduce the risk of SIDS and other sleep-related causes of infant death. Retrieved February 23, 2017 from: https://www.nichd.nih.gov.

Strehle, E., Gray, W., Gopisetti, S., Richardson. J., McGuire, J., and Malone, S. (2012, January) Can home monitoring reduce mortality in infants at increased risk of sudden infant death syndrome? A systematic review. Acta Paediatrica ;101(1):8-13.. Abstract retrieved February 27, 2017 from PubMed database.

Tieder, J., Altman, R., Bonkowsky, J., Brand, D., Claudius, I., Cunningham, D., et. al. (2013)  Management of apparent life-threatening events in infants: a systematic review. Journal of Pediatrics; 2013;163:94-9. (Level 1 evidence)

Trachtenberg, F., Haas, E., Kinney, H., Stanley, C., and Krous, H. (2011, December) Risk factor changes for sudden infant death syndrome after initiation of back-to-sleep campaign. Pediatrics; 129:630–638. (Level 1 evidence)

U. S. Food and Drug Administration (2002, January) Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K011579 (SmartMonitor 2) Retrieved December 12, 2016 from: http://www.fda.gov.

ORIGINAL EFFECTIVE DATE:  4/1981

MOST RECENT REVIEW DATE:  8/23/2017   

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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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