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LCD - Apnea Monitor

Coverage Summary

Home apnea monitoring may be considered medically necessary for premature infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia, for up to three months after hospital discharge, or after the cessation of serious episodes for 14 consecutive days, whichever comes last.

Order Requirements

  1. Patient Name
  2. Specific description of ordered items to be delivered
  3. Prescribed settings (Low Heart Rate, High Heart Rate, Apnea Seconds)
  4. Prescribed frequency of use
  5. Length of Medical Need
  6. Treating Physician’s NPI
  7. Treating physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance).
  8. Treating physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance).
  9. Start date of the order – if different than signature date.

Coverage Detail

Home cardiorespiratory monitoring may be considered medically necessary in infants younger than 12 months of age in the following situations:

  • Those who have experienced an apparent life-threatening event (ALTE); 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 apnea and apnea of prematurity; OR
  • Those with chronic lung disease (i.e., bronchopulmonary dysplasia), particularly those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation.

Home cardiorespiratory monitoring is considered not medically necessary when prescribed to prevent sudden infant death syndrome (SIDS), or for infants with any siblings with a history of SIDS, but without at least one of the indications cited above.

Home cardiorespiratory monitoring in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, is considered experimental, investigational and/or unproven and non-covered.