Home Apnea Monitoring / Home Cardiorespiratory Monitoring
DESCRIPTION
Home cardiorespiratory 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 and in other infants at risk of apnea. An alarm sounds if there is respiratory cessation (central apnea) beyond a predetermined time limit (e.g., 20 seconds) or if the heart rate falls below a preset rate to notify the parent that intervention (stimulation, mouth-to-mouth resuscitation, cardiac compressions) is required.
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
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 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.
MEDICAL APPROPRIATENESS
Home cardiorespiratory monitoring is considered medically appropriate if ANY ONE of the following criteria are met:
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)
IMPORTANT REMINDER
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 or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
SOURCES
American Academy of Pediatrics. (2016). Brief resolved unexplained events (formerly apparent life threatening events) and evaluation of lower-risk infants. Retrieved August 7, 2020 from https://www.aap.org/.
American Academy of Pediatrics. (2022, July). Sleep-related infant deaths: updated 2022 recommendations for reducing infant deaths in the sleep environment. Retrieved July 1, 2022 from https://www.aap.org/.
American Academy of Pediatrics. Committee on Fetus and Newborn. (2008; reaffirmed November 2018). Hospital discharge of the high-risk neonate. Retrieved February 16, 2016 from https://www.aap.org/.
American Academy of Pediatrics: Committee on Fetus and Newborn. (2003). Apnea, sudden infant death syndrome, and home monitoring. Retrieved February 27, 2017 from https://www.aap.org/.
BlueCross BlueShield Association. Evidence Positioning System. (7:2023). Home Cardiorespiratory Monitoring (1.01.06). Retrieved October 9, 2023 from www.bcbsaoca.com/eps/. (10 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)
ORIGINAL EFFECTIVE DATE: 4/1981
MOST RECENT REVIEW DATE: 12/14/2023
ID_BA
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.
This document has been classified as public information.