OAR 410-122-0240: Apnea Monitors for Infants

(1) Indications and limitations of coverage and medical appropriateness: (a) For infants less than twelve (12) months of age with documented apnea, or who have known risk factors for life-threatening apnea, the Division may cover home apnea monitors and related supplies for any of the following indications: (A) Up to three (3) months for: (i) Apnea of prematurity: Sudden cessation of breathing that lasts for at least 20 seconds, is accompanied by bradycardia (heart rate less than 80 beats per minute), or is accompanied by oxygen desaturation (O2 saturation less than 90 percent or cyanosis) in an infant younger than 37 weeks gestational age; (ii) Apparent life-threatening event (ALTE): An episode that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging; (iii) Documented gastroesophageal reflux disease (GERD) that results in apnea, bradycardia, or oxygen desaturation; (iv) Documented prolonged apnea of greater than 20 seconds in duration; (v) Documented apnea accompanied by bradycardia to less than 80 beats per minute; (vi) Documented apnea accompanied by oxygen desaturation (below 90 percent), cyanosis, or pallor; (vii) Documented apnea accompanied by marked hypotonia; (viii) When off medication for bradycardia previously treated with caffeine, theophylline, or similar agents; (B) Upon discharge from an acute care facility for up to one month post-diagnosis for diagnosis of pertussis with positive cultures; (C) As the later sibling of an infant who died of Sudden Infant Death Syndrome (SIDS), until the later sibling is one (1) month older than the age at which the earlier sibling died and remains event-free; (D) On a case-by-case basis for: (i) Infants with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise; (ii) Infants with neurologic or metabolic disorders affecting respiratory control; (iii) Infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation; (b) Infant apnea monitors are usually considered medically appropriate for no longer than approximately three months except for specific conditions listed above; (c) The rental fee includes all training, instruction, assistance, 24-hour on-call support, and any other needed services for effective use of the apnea monitor, including cardiopulmonary resuscitation training. The durable medical equipment prosthetics orthotics and supplies (DMEPOS) provider is responsible for ensuring delivery of these services; (d) The Division may cover related supplies necessary for the effective functioning of the apnea monitor for a three (3) month period based on the following limitations: (A) Electrodes, per pair (A4556) — 3 units; (B) Lead wires, per pair (A4557) — 2 units; (C) Conductive paste or gel (A4558) — 1 unit; (D) Belts (A4649) — 2 units; (e) The cost of apnea monitor rental includes the cost of cables; (f) The Division does not cover apnea monitors with memory recording (E0619) when the attending practitioner is monitoring the infant with ongoing sleep studies and pneumograms. (2) Coding guidelines: For billing purposes, use diagnosis code 798.0, Sudden Infant Death Syndrome (SIDS), for later siblings of infants who died of SIDS. (3) Documentation requirements: Submit the following information with the prior authorization (PA) request: (a) Documentation (medical records including hospital records, sleep studies, practitioner’s progress notes, practitioner-interpreted report from an apnea monitor with memory recording, etc.) of the episode or episodes that led to the diagnosis; (b) An order from the practitioner who diagnosed the infant as having clinically significant apnea or known risk factors for life-threatening apnea. The practioner’s order shall indicate the specific type of apnea monitor (with or without recording feature) and detailed information about the type and quantity of related supplies needed; (c) For an apnea monitor with recording feature (E0619), submit documentation that supports why an apnea monitor without recording feature (E0618) is not adequate to meet the medical need; (d) When dispensing and billing for an item in Table 122-0240, the provider shall ensure that documentation corroborates that all criteria in this rule are met; (e) The DMEPOS provider shall maintain documentation and make it available to the Division upon request. (4) Table 122-0240. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]