Home Apnea Monitoring / Home Cardiorespiratory Monitoring
Home apnea monitors 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 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 sounds 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 children older than one year of age. However, there may be a subset of young children who require cardiorespiratory monitoring beyond one year of age, such as certain individuals 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.
Home cardiorespiratory monitoring (e.g., apnea monitor) for infants is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Home cardiorespiratory monitoring is considered not medically necessary in infants who are siblings of a sudden infant death syndrome child, and do not have any of the indications listed in the appropriateness criteria.
Home cardiorespiratory monitoring in all other conditions/diseases, including but not limited to the diagnosis of obstructive sleep apnea, is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Home cardiorespiratory monitoring is considered medically appropriate if ANY ONE of the following criteria are met:
Infant has experienced a brief resolved unexplained event (formerly known as an apparent life-threatening event; and defined as an episode of less than one minute with a return to baseline following the episode that is frightening to the observer and characterized by some combination of apnea, color change, marked change in breathing, muscle tone, level of consciousness)
Infant is vulnerable to airway compromise related to tracheostomy or anatomic abnormality
Infant has a neurologic or metabolic disorder affecting respiratory control, including central apnea and apnea of prematurity
Infant has a chronic lung disease (e.g., bronchopulmonary dysplasia)
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
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. (2016, January). Apnea of prematurity. Retrieved February 18, 2016 from http://pediatrics.aappublications.org.
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. 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.
BlueCross BlueShield Association. Medical Policy Reference Manual. (1:2017). Home Cardiorespiratory Monitoring (1.01.06). Retrieved February 24, 2017 from BlueWeb. (16 articles and/or guidelines reviewed)
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,163, 94-99. (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: 4/12/2018
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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