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• Those who have experienced an apparent life-threatening event; OR
• Those with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise; OR
• Those with neurologic or metabolic disorders affecting respiratory control, including central sleep apnea; OR
• Those with chronic lung disease (i.e., bronchopulmonary dysplasia), particularly those requiring supplemental oxygen; continuous positive airway pressure; or mechanical ventilation.

Home apnea monitoring (pneumogram) is considered not medically necessary in infants with any siblings with a history of sudden infant death syndrome (SIDS), but without at least one of the indications cited.

Home cardiorespiratory monitoring (pneumogram) in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, is considered investigational.

An apparent life-altering event is defined as an episode that is frightening to observe and is characterized by some combination of apnea, color change, marked change in muscle tone, choking, or gagging.

As suggested by the American Academy of Pediatrics, the physician should establish a review of the problem, a plan of care, and a specific plan for periodic review and termination. Clear documentation of the reasons for continuing monitoring is necessary should monitoring beyond 43 weeks' postmenstrual age be recommended.

Home monitoring is generally not considered appropriate for pediatric patients older than one (1) year of age. Home monitors should be equipped with an event recorder. 

8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)

9/1999: Policies merged; interim policy changes made

11/1999: Revisions to interim policy approved by MPAC

2/27/2002: Managed Care Requirements deleted

3/6/2002: Individual consideration requirement deleted

5/1/2002: Type of Service and Place of Service deleted

3/12/2003: Code Reference section updated

7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003

11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added

9/12/2006:  Coding updated.  ICD9 2006 revisions added to policy

10/18/2006: Policy reviewed, no changes

12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions

7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. Removed the following not medically necessary indications: backup electrical system or any alteration to the living quarters for the monitor, parental training sessions (ie., CPR), and standby medical, technical or counseling assistance. CPT 94772 removed. ICD-9 diagnosis codes 770.20, 770.12, 770.14, 770.16, 770.18 added.

9/29/2009: Code Reference section updated. New ICD-9 diagnosis codes 768.70, 768.71, 768.72, 768.73 added to covered table. Deleted statement added to ICD-9 diagnosis code 768.7.

06/24/2010: Policy Description was revised with additional information about home apnea monitors.  The Policy Statement section was revised to add "pneumogram" and clarify home cardiorespiratory monitoring may be considered medically necessary for specific situations in infants younger than 12 months of age.  An additional statement was added  - Home cardiorespiratory monitoring (pneumogram) in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, is considered investigational. Policy Guidelines section was revised to add definition of an apparent life-altering event, home monitoring is generally not considered appropriate for pediatric patients older than one (1) year of age, and home monitors should be equipped with an event recorder.

04/20/2011: Policy reviewed; no changes.

04/19/2012: Policy reviewed; no changes.

04/19/2013: Policy reviewed; no changes.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes 

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