I'm a provider
You will be redirected to myBlue. Would you like to continue?
Please wait while you are redirected.
Please enter a username and password.
Home apnea monitors track respiratory effort and heart rate to detect episodes of apnea. They have been proposed for a variety of indications including but not limited to children at increased risk of sudden infant death syndrome (SIDS) and children who have experienced a life-threatening event.
Home apnea monitors are devices that generally monitor both respiratory and heart rates, and are typically utilized 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 post-conceptual 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 (e.g., 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 two-channel devices, home apnea monitors are not effective at 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.
SIDS refers to the sudden death of an infant younger than one 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 over time, scientific medical studies failed to establish that the use of home monitoring reduced the incidence of SIDS. In 2011, the 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. One of these proven practices, supine sleeping, has been promoted in the “Safe to Sleep” campaign (formerly called the “Back to Sleep” campaign) initiated in 1994 by AAP, as well as by the National Institute of Child Health and Development and the Maternal Child Health Bureau of Human Resources and Services Administration. The campaign is a national process to educate health care professionals, parents, and caregivers about the significance of placing infants in the supine sleeping position to reduce SIDS. The incidence of SIDS in the United States decreased dramatically between 1992 and 2001, especially in the years after the first supine sleep position recommendations were issued. The incidence of SIDS has remained relatively constant since 2001, and SIDS remains a major cause of infant mortality in the United States.
A number of infant apnea monitors have been cleared for marketing by FDA. One device is the SmartMonitor 2 Apnea Monitor (Philip Children’s Medical Ventures, Respironics), which was cleared for marketing through the 510(k) process in October 2003. The intended use is for continuous monitoring of respiration, heart rate, and SpO2 (pulse oximetry of infant patients) in a hospital or home environment.
Home cardiorespiratory monitoring (pneumogram) may be considered medically necessary in infants younger than 12 months of age in the following situations:
Home cardiorespiratory 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.
This policy does not address the use of home monitoring for the diagnosis and management of obstructive sleep apnea. If obstructive sleep apnea is a consideration, refer to the Sleep Disorders medical policy.
An apparent life-threatening 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.
This policy applies only to the use of U.S. Food and Drug Administration (FDA)‒approved home monitoring systems. A variety of commercially available baby monitoring devices are marketed to parents for monitoring infants’ sleep, breathing, and behavior. Although some of the devices include pulse oximetry, these devices are not sold as medical devices and are therefore not cleared for marketing by FDA.
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' postconceptual age be recommended. Home cardiorespiratory monitoring for apnea is generally not considered appropriate for pediatric patients older than one (1) year of age. There may be a subset of young children who require cardiorespiratory monitoring beyond one (1) year of age, such as certain patients with home noninvasive or invasive ventilator use or chronic lung disease.
Home monitors should be equipped with an event recorder.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
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.
05/02/2014: Policy reviewed; description updated. Removed the word sleep from "central sleep apnea," and added "and apnea of prematurity" in the medically necessary policy statement. Replaced the word apnea with "cardiorespiratory" in the second policy statement. Added statement to the policy guidelines section that certain children may require monitoring beyond one (1) year. Removed the deleted ICD-9 code 768.7 from the Code Reference section.
03/31/2015: Policy description updated regarding SIDS. Policy statements unchanged. Policy guidelines updated to state that this policy does not address the use of home monitoring for the diagnosis and management of obstructive sleep apnea. This policy only applies to the use of U.S. FDA-approved home monitoring systems. Added medically necessary and investigational definitions to the policy guidelines.
08/28/2015: Medical policy revised to add ICD-10 codes. Code descriptions updated for CPT codes 94774 and 94777.
05/26/2016: Policy number added.
Blue Cross Blue Shield Association Policy #1.01.06
This may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.