Coverage Policy Manual
Policy #: 1998024
Category: DME
Initiated: January 1993
Last Review: June 2022
  Home Cardiorespiratory Monitoring

Description:
Home cardiorespiratory monitors track respiratory effort and heart rate and have been 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’ postconceptual 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 2-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.
 
The American Academy of Pediatrics (AAP) defines Sudden Unexpected Infant Death (SUID), also known as Sudden Unexpected Death In Infancy (SUDI) as “any sudden and unexpected death, whether explained or unexplained” that occurs during infancy. Sudden infant death syndrome (SIDS) is a subcategory or SUID/SUDI, which is defined as the sudden death of an infant younger than 1 year of age whereby 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, clinical studies have failed to establish that the use of home monitoring reduces the incidence of SIDS. The American Academy of Pediatrics (AAP) recommends that home monitoring should not be used as a strategy to prevent SIDS. Instead, the 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 (NICHD) and the Maternal Child Health Bureau of Human Resources and Services Administration. The campaign is a national effort to educate healthcare professionals, parents, and caregivers about the significance of placing infants in the supine sleeping position to reduce SIDS (NICHD, 2013). The incidence of SIDS in the U.S. decreased dramatically between 1992 and 2001, especially in the years after the first supine sleep position recommendations were issued.
 
The 2016 AAP clinical practice guideline published by Tieder et al defined brief resolved unexplained event (BRUE; formerly apparent life-threatening event [ALTE]) as: "An event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of 1 of the following (Tieder, 2016):
    • cyanosis or pallor;
    • absent, decreased, or irregular breathing;
    • marked change in tone (hyper- or hypotonia); and altered level of responsiveness."
 
According to AAP’s 2008 Policy Statement on Hospital Discharge of the High-Risk Neonate reported by Stark et al (Reaffirmed in 2018), there has been recent increases in discharge of infants dependent on some form of supportive technology due to special health care needs or unresolved medical problems (Stark, 2008). Conditions that may necessitate use of technological support include apnea of prematurity and bronchopulmonary dysplasia for preterm infants, and upper airway anomalies, central nervous system disorders, and neuromuscular disorders for term infants (Velumula, 2020). For example, home ventilation can be required for infants with tracheostomy for upper airway abnormalities or who cannot be weaned from assisted ventilation prior to discharge. Additionally, to avoid the potential risks of growth failure and cor pulmonale resulting from marginal oxygenation, discharge with home oxygen therapy has been used for infants with bronchopulmonary dysplasia. In both of these cases, home cardiorespiratory monitoring is recommended to accompany the supportive technology for use in detecting airway obstructions or dislodging of the oxygen.
 
 
Regulatory Status
A number of infant apnea/cardiopulmonary monitors have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process. This includes the SmartMonitor2 Apnea Monitor (Philip Children’s Medical Ventures, Respironics), which is intended for continuous monitoring of respiration, heart rate, and SpO2 (pulse oximetry) of infant patients in a hospital or home environment. FDA product code: NPF and DQA. A search of the U.S. FDA 510(k) website in May 2022 did not identify any new safety information that would likely influence this policy.
 
Coding
The following CPT codes may be used:
 
94772: Circadian respiratory pattern recording (pediatric pneumogram), 12–24 hour continuous recording, infant
 
94774: Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, review, interpretation, and preparation of a report by a physician or other qualified health care professional.
 
94775: monitor attachment only (includes hook-up, initiation of recording and disconnection)
 
94776: monitoring, download of information, receipt of transmission(s) and analyses by computer only
 
94777: review, interpretation and preparation of report only by a physician or other qualified health care professional.

Policy/
Coverage:
Effective November 1, 2020
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Home apnea or cardiorespiratory monitoring (pneumogram) meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes in infants with special health care needs or dependence on home technological support when initiated in infants younger than 12 months of age in the following situations:
 
    • 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.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Home apnea or home cardiorespiratory monitoring when used as a strategy to reduce the risk of Sudden Infant Death Syndrome (SIDS) does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without member benefit certificate primary coverage criteria, home apnea or home cardiorespiratory monitoring (pneumogram) when used as a strategy to reduce the risk of SIDS, is considered investigational.  Investigational services are exclusions in most member benefit certificate of coverage.
 
Home apnea or home cardiorespiratory monitoring does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness when used for cardiopulmonary evaluation in lower-risk infants following a brief resolved unexplained event (BRUE), which was previously known as an apparent life threatening event (ALTE) (see Policy Guidelines for further discussion of BRUE risk).
 
For contracts without member benefit certificate primary coverage criteria, home apnea or home cardiorespiratory monitoring (pneumogram) when used for cardiopulmonary evaluation in lower-risk infants following a brief resolved unexplained event (BRUE), which was previously known as an apparent life threatening event (ALTE), is considered investigational.  Investigational services are exclusions in most member benefit certificate of coverage.
 
Note:  
Patient factors identified as determining lower risk following a BRUE are as follows:
 
        • Age greater than 60 days
        • Prematurity (gestational age greater or equal to 32 weeks and postconceptional age less than or equal to 45 weeks
        • First BRUE (no previous BRUE and not occurring in clusters)
        • Event duration less than 1 minute
        • No CPR required by trained medical provider
        • No concerning historical features (e.g. possible child abuse, history of the event, recent history, past medical history, family history, environmental history, social history)
        • No concerning physical examination findings (e.g. general appearance, growth variables, vital signs, skin, head, eyes, ears, nose and mouth, neck, chest, heart, abdomen, genitalia, extremities, neurologic)
 
Home apnea or cardiorespiratory monitoring (pneumogram) in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without member benefit certificate primary coverage criteria, home apnea or cardiorespiratory monitoring (pneumogram) in all other conditions, including but not limited to the diagnosis of obstructive sleep apnea, are considered investigational.  Investigational services are exclusions in most member benefit certificate of coverage.
 
Effective Prior to November 1, 2020
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Home apnea or cardiorespiratory monitoring (pneumogram) meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes in infants less than 12 months of age in the following situations:
    • 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 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.
 
Note: 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.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Home cardiorespiratory monitoring (pneumogram) in infants with any siblings with a history of sudden infant death syndrome (SIDS), without at least one of the indications cited above, does not meet member benefit certificate primary coverage criteria based on scientific evidence and published professional standards.
 
For members with contracts without primary coverage criteria, home cardiorespiratory monitoring (pneumogram) in infants with any siblings with a history of sudden infant death syndrome (SIDS), without at least one of the indications cited above, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Home apnea or cardiorespiratory monitoring (pneumogram) in all other conditions does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without member benefit certificate primary coverage criteria, home apnea or cardiorespiratory monitoring (pneumogram) in all other conditions, are considered investigational.  Investigational services are exclusions in most member benefit certificate of coverage.
 
Effective, February 2010 – April 2013
Home apnea or cardiorespiratory monitoring (pneumogram) meets primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes in infants less than 12 months of age in the following situations:
    • 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; OR
    • Those with chronic lung disease (i.e., bronchopulmonary dysplasia), particularly those requiring supplemental oxygen; continuous positive airway pressure; or mechanical ventilation.
 
Note: 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.
 
Individual consideration should be given to:
    • The medical necessity for continued use of a home monitor when used after an infant is 12 months of age;
    • Infants with any siblings who were Sudden Infant Death Syndrome (SIDS) victims.
 
Home apnea or cardiorespiratory monitoring (pneumogram) in all other conditions does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness.
 
For contracts without member benefit certificate primary coverage criteria, home apnea or cardiorespiratory monitoring (pneumogram) in all other conditions, are considered investigational.  Investigational services are exclusions in most member benefit certificate of coverage.
 
Effective February 1998 - January 2010
Home apnea monitoring meets primary coverage criteria for effectiveness and is covered for infants who have been diagnosed as having clinically significant recurrent apnea when used with the following guidelines:
    • The monitor must be prescribed by the physician who diagnosed the infant as having clinically significant apnea that is recurrent and severe;
    • Documentation of the episode or episodes that lead to the diagnosis must be included.  
 
Individual consideration should be given to:
    • The medical necessity for continued use of a home monitor when used after an infant is 12 months of age;
    • Infants with any siblings who were Sudden Infant Death Syndrome (SIDS) victims.
 
Clinically significant apnea is defined as a condition in which:
    • Breathing stops for 20 seconds or longer; or
    • Breathing stops and is accompanied by slowing of heart beat (bradycardia) or bluish discoloration of the skin or mucous membrane, caused by too little oxygenated hemoglobin in the bloodstream (cyanosis).  
 
Coverage is not provided for:
    • A backup electrical system;
    • Parental training sessions, including cardiopulmonary resuscitation (CPR) or instructions in the use of the monitor when identified as a separate charge.  These charges are usually included in the rental or purchase fee.  
 
Coverage for SIDS monitors include the following:
    • Accessories necessary for effective functioning of covered equipment;
    • Adjustment, repair, and replacement of the device.

Rationale:
This policy was initiated in 1993 with evidence review of the effectiveness of home apnea monitoring. It has since been updated regularly with searches of the PubMed database. The most recent literature update was performed through June 29, 2020.
 
Prevention of Sudden Infant Death Syndrome (SIDS)
 
In a 2016 literature review, that supported the American Academy of Pediatrics' (AAP) 2016 Policy Statement on SIDS, Moon et al identified 4 large epidemiological studies conducted between 1986-2001 which found that the use of home cardiorespiratory monitors did not decrease the incidence of SIDS (Moon, 2016). Among those 4 studies is the Collaborative Home Infant Monitoring Evaluation (CHIME) study, a longitudinal cohort study conducted from 1994 to 1998, which was designed to address whether severe episodes of apnea and bradycardia occur more commonly in infants considered at higher risk for SIDS (Hoppenbrouwers, 2018). The study included 1079 infants, both healthy and considered at high-risk for SIDS based on a history of an apparent life-threatening event (ALTE), siblings with SIDS, and preterm gestation, who were observed with home cardiorespiratory monitoring for the first 6 months after birth. Monitor alarms were set off frequently across all risk groups, occurring in 41% of all subjects. So-called "extreme" events occurred in all groups but preterm infants were at higher risk until 43 weeks postconceptual age. The authors concluded that episodes of prolonged apnea or bradycardia primarily occurred before the developmental age when most SIDS deaths occurred. In a subsequent multivariate logistic regression analysis of the CHIME study data, Hoppenbrouwers et al found that extreme events were not significantly associated with any known SIDS risk Factors (Hoppenbrouwers, 2008).
 
Findings from a prior systematic review of the literature on the impact of home monitoring (apnea monitoring, respiratory monitoring, or cardiorespiratory monitoring) published in 2012 by Strehle et al, are consistent with the 2016 AAP literature review (Moon, 2016; Strehle, 2012). The systematic review by Strehle et al in 2012 searched the literature through June 2010 and included 1 pilot study that assessed the feasibility of an RCT to evaluate home monitoring (level I evidence) and 10 unique case series (level III evidence). The body of case series evidence included the CHIME study. Reviewers concluded that there was a lack of high-level evidence that home monitoring would be beneficial in preventing SIDS.
 
Home Cardiorespiratory Monitoring for Other Respiratory Conditions
 
Brief Resolved Unexplained Event (BRUE)
In a 2016 systematic review that supported the AAP's 2016 Clinical Practice Guideline on BRUE, Tieder et al assessed studies relevant to use of home cardiorespiratory monitoring in infants presenting with a lower-risk BRUE (Tieder, 2016). Based on searches of numerous bibliographic databases through December 31, 2014, this systematic review identified several studies published between 1986 and 2008 demonstrating that the frequency of respiratory pauses and bradycardia identified by home cardiorespiratory monitors is similar in infants with and without respiratory abnormalities. In addition, the review noted that other studies have shown no improvements in outcomes or SIDS prevention with home apnea monitors, and “a lack of correlation between ALTEs [now referred to as BRUE] and SIDS.
 
In addition to the studies summarized in the 2016 AAP systematic review, an observational cohort study by Mittal et al, reported on 4-week follow-up outcomes for 300 infants seen in an emergency department with a diagnosis of ALTE (Mittal, 2013). Of the 228 patients admitted, 110 (48.2%) had in-hospital pneumography (101 with esophageal pH monitoring, 9 without esophageal pH monitoring). Of those with pneumography, 33 patients had apnea, with or without evidence of gastroesophageal reflux. There was no significant association between positive findings on pneumography and recurrent ALTE in the four weeks after hospitalization. Study limitations included nonstandardized evaluation of patients with ALTE and whether results of an in-hospital pneumography study translate to the home setting.
 
Infants With Special Health Care Needs or Dependence on Home Technological Support
Home apnea monitors are sometimes used in neonates with apnea, bradycardia, and oxygen desaturation events. Apnea of prematurity is extremely common in preterm infants but may also occur in late preterm infants. In many cases, infants with these events are observed in the hospital until a "safe" period without an event occurs, but some infants are discharged to home with a home monitor. For example, in a 3-center, 5-year case series reporting on the evaluation and management of apnea, bradycardia, and oxygen desaturation events in infants born at 34 or more weeks of gestational age, Veit et al reported that 4.5% of infants were discharged to home with a monitor (Veit, 2016). However, there is a lack of evidence on the effectiveness of home cardiorespiratory monitors in these conditions. For many conditions, trials would be difficult to perform due to small numbers of patients and logistic difficulties for these conditions that would make trial enrollment difficult. As a result, the best available recommendations for treatment currently rely on expert consensus.
 
Evidence for the use of home cardiorespiratory monitoring for lower-risk BRUE consists of a systematic review and several observational cohort studies. These studies found no significant differences between infants with and without respiratory abnormalities in the frequency of respiratory pauses and bradycardia identified by home cardiorespiratory monitors. There is a lack of published evidence for other respiratory conditions, which is likely due to small numbers of patients and the difficulty of enrolling infants with respiratory conditions.
 
For individuals with risk of respiratory failure in infancy who receive home cardiorespiratory monitoring for prevention of Sudden Infant Death Syndrome (SIDS), the evidence includes a systematic review and large epidemiological studies, including the Collaborative Home Infant Monitoring Evaluation (CHIME) study. Relevant outcomes are overall survival and morbid events. The systematic review and epidemiological studies consistently found that the use of home cardiorespiratory monitors did not decrease the incidence of SIDS. The evidence is sufficient to determine that the technology is unlikely to improve the net health outcome.
 
For individuals with risk of respiratory failure in infancy who receive home cardiorespiratory monitoring for other respiratory conditions, the evidence includes a systematic review and several observational cohort studies. Relevant outcomes are overall survival and morbid events. For lower-risk infants following a brief resolved unexplained event (BRUE), which was previously known as an apparent life threatening event (ALTE), the systematic review and observational cohort studies found no significant differences between infants with and without respiratory abnormalities in the frequency of respiratory pauses and bradycardia identified by home cardiorespiratory monitors. There is a lack of published evidence for other respiratory conditions, which is likely due to small numbers of patients and the difficulty of enrolling infants with respiratory conditions. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
Clinical Input From Physician Specialty Societies and Academic Medical Centers
While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.
 
In response to requests, input was received from 2 specialty societies and 2 academic medical centers while this policy was under review in 2017. There was general agreement with the existing medically necessary statements, including those that addressed use for tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise; those with neurologic or metabolic disorders affecting respiratory control, including central apnea and apnea of prematurity; or those with chronic lung disease (ie, bronchopulmonary dysplasia).
 
Practice Guidelines and Position Statements
 
American Academy of Pediatrics
Sudden infant Death Syndrome (SIDS)
In 2016, the American Academy of Pediatrics (AAP) (reported by Moon et al) issued a Policy Statement on SIDS and other Sleep-Related Infant Deaths, which addressed the use of home cardiorespiratory monitors (Moon, 2016). Based on a literature review that identified evidence from 4 large epidemiological studies conducted between 1986-2001, this Policy Statement issued an A-level recommendation against the use of home cardiorespiratory monitoring as a SIDS-prevention strategy. The recommendation stated "Do not use home cardiorespiratory monitors as a strategy to reduce the risk of SIDS.” The A-level recommendation indicates that "there is good-quality patient-oriented evidence based on the Strength-of-Recommendation Taxonomy (SORT)." Conflict of interest management was described as including authors filing conflict of interest statements with the AAP and resolution of any conflicts through a process approved by the Board of
Directors.
 
Brief Resolved Unexplained Events (BRUE)
In 2016, the AAP issued clinical practice guidelines on brief resolved unexplained events (BRUE), which addressed the use of home cardiorespiratory monitoring for low-risk infants (Tieder, 2016; AAP, 2013). This clinical practice guideline was based on a systematic review with searches through December 31, 2014 and the evidence and strength of the recommendations were formally rated using a well-described approach. As with the AAP SIDS Policy Statement described above, conflict of interest management was described as including authors filing conflict of interest statements with the AAP and resolution of any conflicts through a process approved by the Board of Directors. The recommendation stated "Clinicians should not initiate home cardiorespiratory monitoring for cardiopulmonary evaluation." The evidence quality was rated as B, which indicates it was based on "Trials or diagnostic studies with minor limitations; consistent findings from multiple observational studies." The strength of the recommendation was moderate, indicating that "A particular action is favored because anticipated benefits clearly exceed harms (or vice versa) and the quality of evidence is good but not excellent (or is unobtainable). Clinicians would be prudent to follow a moderate recommendation but should remain alert to new information and sensitive to patient preferences."
 
Infants With Special Health Care Needs or Dependence on Home Technological Support
In 2003, the policy statement published by AAP, addressed the use of home apnea monitors for other respiratory conditions (AAP, 2003). The AAP policy statement identified infants who could benefit from home monitoring, not because of an increased risk of SIDS but because of other factors that increase the risk of sudden death. These infants include those who have experienced an ALTE, tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise, neurologic or metabolic disorders affecting respiratory control, chronic lung disease (ie, bronchopulmonary dysplasia), particularly those requiring supplemental oxygen; continuous positive airway pressure; or mechanical ventilation. An important limitation of this 2003 AAP policy statement is that it was retired in 2012.
 
The AAP (2008, reaffirmed in 2018) also published a Policy Statement by Stark et al on the hospital discharge of high-risk neonates that addressed the role of home apnea monitors for preterm and otherwise high-risk infants (Stark, 2008).This Policy Statement was not clearly based on a systematic review, strength of the policy statements was not formally rated, and clear documentation of conflict of interest management is lacking. Relevant statements include:
 
    • Hospitalized infants still at risk of apnea:"Home monitors are rarely indicated for detection of apnea solely because of immature respiratory control, in part because infants with immature respiratory control, in general, are still hospitalized until they are no longer at risk of apnea of prematurity. Use of a home monitor does not preclude the need for demonstrated maturity of respiratory control before discharge and should not be used to justify discharge of infants who are still at risk of apnea. Home monitors are not indicated for prevention of sudden infant death syndrome (SIDS) in preterm infants, although preterm infants are at increased risk of SIDS."
 
    • Bronchopulmonary dysplasia: “Home oxygen therapy for infants with bronchopulmonary dysplasia has been used as a means of achieving earlier hospital discharge while avoiding the risks of growth failure and cor pulmonale resulting from marginal oxygenation.” “Infants who are discharged on supplemental oxygen are often also discharged on a cardiorespiratory monitor or pulse oximeter in case the oxygen should become dislodged or the supply depleted.”
 
    • Tracheostomy: “Tracheostomy is sometimes required for neonates with upper airway abnormalities or occasionally for infants who cannot be weaned from assisted ventilation. Good parental teaching and coordinated multidisciplinary follow-up care are essential for these infants. Infants who require home ventilation should also be on a cardiorespiratory monitor in case the airway should become obstructed, but the home ventilator should also have a disconnect alarm to alert caregivers to ventilator disconnection. Home ventilation requires qualified personnel to provide bedside care; in most cases, home-nursing support will be needed for at least part of the day.
 
2021 Update
Annual policy review completed with a literature search using the MEDLINE database through May 2021. No new literature was identified that would prompt a change in the coverage statement.
 
2022 Update
Annual policy review completed with a literature search using the MEDLINE database through May 2022. No new literature was identified that would prompt a change in the coverage statement.

CPT/HCPCS:
94772Circadian respiratory pattern recording (pediatric pneumogram), 12 24 hour continuous recording, infant
94774Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30 day period of time; includes monitor attachment, download of data, review, interpretation, and preparation of a report by a physician or other qualified health care professional
94775Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30 day period of time; monitor attachment only (includes hook up, initiation of recording and disconnection)
94776Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30 day period of time; monitoring, download of information, receipt of transmission(s) and analyses by computer only
94777Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30 day period of time; review, interpretation and preparation of report only by a physician or other qualified health care professional
A4556Electrodes, (e.g., apnea monitor), per pair
A4557Lead wires, (e.g., apnea monitor), per pair
E0618Apnea monitor, without recording feature
E0619Apnea monitor, with recording feature

References: . Eichenwald EC, Committee on F, Newborn AAoP(2016) Apnea of Prematurity. Pediatrics. Jan 2016;137(1). PMID 26628729

AAP(2012) AAP Publications Reaffirmed and Retired. Pediatrics. August 1 2012;130(2):e467-e468.

Am Academy of Pediatrics; Committee on Fetus and Newborn.(2003) Apnea, sudden infant death syndrome, and home monitoring. Pediatrics 2003;111(4 pt 1):914-7.

American Academy of Pediatrics Committee on Fetus and Newborn.(2008) Hospital discharge of the high-risk neonate. Pediatrics, 2008; 122:1119-1126.

American academy of Pediatrics Policy Statement .(2005) Task Force on Sudden Infant Death Syndrome. Pediatrics, 2005; 116:1245-55.

Fetus Co, Newborn.(2008) Hospital Discharge of the High-Risk Neonate. Pediatrics 2008; 122(5):1119-26.

Halbower AC.(2008) Pediatric home apnea monitors: coding, billing, and updated prescribing information for practice management. Chest 2008; 134(2):425-9.

Hodgman JE, Hoppenbrouwers T.(1988) Home monitoring for the sudden infant death syndrome. The case against. Ann N Y Acad Sci, 1988; 533:164-75.

Hoppenbrouwers T, Hodgman JE, Ramanathan A et al.(2008) Extreme and conventional cardiorespiratory events and epidemiologic risk factors for SIDS. J Pediatr 2008; 152(5):636-41.

Jobe AH, Bancalari E.(2001) Bronchopulmonary dysplasia. Am J Respir Crit Care Med. Jun 2001;163(7):1723-1729. PMID 11401896

McGovern MC, Smith MB.(2004) Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child 2004; 89(11):1043-8.

Mittal MK, Donda K, Baren JM.(2013) Role of pneumography and esophageal pH monitoring in the evaluation of infants with apparent life-threatening event: a prospective observational study. Clin Pediatr (Phila). Apr 2013;52(4):338-343. PMID 23393308

Monod N, Piouin P, et al.(1986) Are polygraphic and cardiopneumographic respiratory patterns useful tools for predicting the risk for sudden infant death syndrome? A 10-year study. Biol Neonate, 1985; 50:147-53.

Moon RY, Darnall RA, Feldman-Winter L, et al.(2016) SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment. Pediatrics. Nov 2016; 138(5). PMID 27940805

Moon RY, Darnall RA, Feldman-Winter L, et al.(2016) SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Pediatrics. Nov 2016; 138(5). PMID 27940804

Moon RY, Moon RY, Darnall RA, et al.(2011) SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. Nov 2011; 128(5): 1030-9. PMID 22007004

National Institute of Child Health and Human Development (NICHD).(2018) Safe to Sleep. n.d.; https://www1.nichd.nih.gov/sts/Pages/default.aspx. Accessed May 15, 2018.

Ramanathan R, Corwin MJ, et al.(2001) Cardiorespiratory events recorded on home monitors: comparison of healthy infants with those at increased risk for SIDS. JAMA, 2001; 285:2199-2207.

Stark AR, Adamkin DH, Batton DG, et al.(2008) Hospital discharge of the high-risk neonate. Pediatrics. Nov 2008; 122(5): 1119-26. PMID 18977994

Strehle EM, Gray WK, Gopisetti S et al.(2012) Can home monitoring reduce mortality in infants at increased risk of sudden infant death syndrome: a systematic review. Acta Paediatr 2012; 101(1):8-13.

Task Force on Sudden Infant Death Syndrome, Moon RY.(2011) SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 2011; 128(5):1030-9.

Tieder JS, Altman RL, Bonkowsky JL, et al.(2013) Management of apparent life-threatening events in infants: a systematic review. J Pediatr. Jul 2013;163(1):94-99 e91-96. PMID 23415612

Tieder JS, Bonkowsky JL, Etzel RA, et al.(2016) Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. May 2016;137(5). PMID 27244835

Tieder JS, Cowan CA, Garrison MM et al.(2008) Variation in inpatient resource utilization and management of apparent life-threatening events. J Pediatr 2008; 152(5):629-35, 35 e1-2.

Veit L, Amberson M, Freiberger C, et al.(2016) Diagnostic Evaluation and Home Monitor Use in Late Preterm to Term Infants With Apnea, Bradycardia, and Desaturations. Clin Pediatr (Phila). Mar 7 2016. PMID 26957524

Velumula P, Jani S, Kanike N, et al.(2020) Monitoring of Infants Discharged Home with Medical Devices. Pediatr Ann. Feb 01 2020; 49(2): e88-e92. PMID 32045488

Ward SL, Keens TG, et al.(1985) Sudden infant death syndrome in infants evaluated by apnea programs in California. Pediatrics, 1985; 77:451-8.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2023 American Medical Association.