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Date Printed: June 23, 2017: 06:30 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative 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.

09-E0000-50

Original Effective Date: 05/15/04

Reviewed: 02/23/17

Revised: 03/15/17

Subject: Home Cardiorespiratory Monitoring, Infant

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Home apnea monitors track respiratory effort and heart rate, and have been used to monitor central apnea of prematurity in newly discharged at-risk or high-risk premature infants (infants are at increased risk of cardiorespiratory events until 43 weeks of postconceptual age) and in other infants at risk of apnea. An alarm will sound if there is respiratory cessation (central apnea) beyond a predetermined time limit (eg, 20 seconds) or if the heart rate falls below a preset rate (bradycardia) to notify the parent that intervention (stimulation, mouth-to-mouth resuscitation, cardiac compressions) is required. Unless an oximeter is added to the 2-channel devices, home apnea monitors are not effective for detecting obstructive sleep apneas. False alarms due to movement artifact are common with pulse oximeters, and these devices are not intended for the diagnosis of sleep-disordered breathing in a child.

Sudden infant death syndrome (SIDS) refers to the sudden death of an infant younger than 1 year of age; the circumstances are unexplained after a thorough investigation that includes autopsy, examination of the death scene, and review of the family history. As a means to decrease the incidence of SIDS, in the 1970s, cardiorespiratory monitoring was suggested. However, scientific medical studies have failed to establish that the use of home monitoring reduces the incidence of SIDS. In 2011, the American Academy of Pediatrics (AAP) Task Force on Sudden Infant Death Syndrome reiterated the recommendations of its previous policy statements that home monitoring should not be used as a strategy to prevent SIDS. Instead, AAP recommends that proven practices should be promoted to reduce the incidence of SIDS, which include supine sleeping, use of a firm bed surface, routine immunizations, breast-feeding, and avoidance of exposure to tobacco smoke, alcohol, and illegal drugs.

Home apnea monitors are used for reasons other than preventing SIDS. These include monitoring infants at high risk of respiratory compromise due to chronic ventilator or oxygen requirements, and central apnea, including apnea, bradycardia, and oxygen desaturations associated with prematurity. An additional potential use of home apnea monitors is monitoring infants who have had acute events associated with apnea, color change, or loss of tone.

POSITION STATEMENT:

Home cardiorespiratory monitoring (using an FDA approved home monitoring system) meets the definition of medical necessity when initiated in infants younger than 12 months of age for the following conditions:

Home cardiorespiratory monitoring in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, is considered experimental or investigational. The evidence is insufficient to determine the effects of the technology on health outcomes.

Home cardiorespiratory monitoring is not recommended in infants with siblings that were victims of sudden infant death syndrome (SIDS) and monitors used in these situations do not meet the definition of medical necessity. Home cardiorespiratory monitoring has not been proven to prevent sudden unexpected deaths in infants.

Coverage is not provided for a backup electrical system.

* Brief resolved unexplained event (BRUE): An event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of 1 or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone (hyper- or hypotonia); or altered level of responsiveness.

BILLING/CODING INFORMATION:

The following codes are used for reporting home apnea monitors and associated supplies:

CPT Coding

94772

Circadian respiratory pattern recording (pediatric pneumogram), 12-24 hour continuous recording, infant

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, review, interpretation, and preparation of a report by a physician or other qualified health care professional

94775

Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitor attachment only (includes hook-up, initiation of recording and disconnection)

94776

Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitoring, download of information, receipt of transmission(s) and analyses by computer only

94777

Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; review, interpretation and preparation of report only by a physician or other qualified health care professional

HCPCS Coding

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

REIMBURSEMENT INFORMATION:

Reimbursement for the following services and supplies is included in the rental allowance for the cardiorespiratory monitor:

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

None applicable.

RELATED GUIDELINES:

Durable Medical Equipment (DME), 09-E0000-01

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Pediatrics Policy Statement: Apnea, Sudden Infant Death Syndrome, and Home Monitoring. PEDIATRICS Vol. 120 No. 3 September 2007, pp. 683-684 (doi:10.1542/peds. 2007-1643).
  2. Blue Cross Blue Shield Association Medical Reference Policy 1.01.06, Home cardiorespiratory Monitoring, 01/17.
  3. Eichenwald EC, Committee on Fetus Newborn, American Academy of Pediatrics. Apnea of prematurity. Pediatrics. Jan 2016;137(1).
  4. Halbower AC. Pediatric home apnea monitors: coding, billing, and updated prescribing information for practice management. Chest 2008; 134(2):425-9.
  5. Hayes Alert, “Study Questions Value of Home Apnea Monitors” (05/01).
  6. Infantile Apnea and Home Monitoring. NIH Consensus Statement Online 1986 Sep 29-Oct 1; 6(6): 1-10 (accessed 04/13/09).
  7. Journal of the American Medical Association, “Cardiorespiratory Events Recorded on Home Monitors; Comparison of Healthy Infants with Those at Increased Risk for SIDS” (2001; 285:2199-2207).
  8. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. Nov 2011;128(5):1030-1039.
  9. Tieder JS, Bonkowsky JL, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. May 2016;137(5).
  10. Veit L, Amberson M, Freiberger C, et al. Diagnostic evaluation and home monitor use in late preterm to term infants with apnea, bradycardia, and desaturations. Clin Pediatr (Phila). Nov 2016;55(13):1210-1218.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/23/17.

GUIDELINE UPDATE INFORMATION:

05/15/04

New Medical Coverage Guideline.

05/15/06

Scheduled review; no changes to coverage statement.

01/01/07

Annual HCPCS coding update (added 94774, 94775, 94776, and 94777.)

08/15/07

Review, coverage statements maintained, guideline updated.

05/15/09

Scheduled review; no change in position statement, and updated references.

05/15/11

Scheduled review; position statement unchanged; references updated.

01/01/13

Annual HCPCS coding update: revised descriptors for 94774 and 94777.

05/11/14

Revision: Program Exceptions section updated.

03/15/17

Revision; Position statements revised including changing apparent life-threatening event to brief resolved unexplained event (BRUE) and adding BRUE definition; code 94772 added; description section and references updated.

Date Printed: June 23, 2017: 06:30 PM