Rule 5160-10-09 | DMEPOS: apnea monitors.
(A) Coverage.
(1) Initial payment may be made for rental of an apnea monitor for a period not to exceed four months, and after the first four months payment may be made either for additional rental or for purchase, only if the following conditions are satisfied:
(a) The monitoring unit meets current United States food and drug administration guidelines.
(b) The provider is capable of performing all of the following services:
(i) Arranging to have certified individuals provide infant cardiopulmonary resuscitation (CPR) training to caregivers;
(ii) Providing education and instruction on the mechanical aspects of monitors; and
(iii) Providing a technician twenty-four hours a day to service monitoring equipment;
(c) For this initial rental period, the following information is recorded:
(i) At least one clinical indication from the following list:
(a) The occurrence of at least one apparent life-threatening event (ALTE) requiring mouth-to-mouth resuscitation or vigorous stimulation;
(b) A need for active medical management of apnea of prematurity;
(c) The occurrence of sudden infant death syndrome (SIDS) in a sibling;
(d) A need for home oxygen therapy or ventilatory support (either invasive or non-invasive) and associated technology-dependence;
(e) Tracheotomy and associated technology-dependence;
(f) An abnormal pneumogram at discharge from a medical facility;
(g) Severe gastroesophageal reflux and associated apnea;
(h) Severe upper airway abnormality (e.g., achondroplasia, Pierre Robin syndrome); or
(i) Another, specified disorder necessitating close cardiorespiratory monitoring to facilitate a more timely discharge to home from a medical facility; and
(ii) An attestation that appropriate caregivers are capable of being trained to use the monitor properly; and
(d) For additional rental or purchase, the following information is recorded:
(i) An attestation by the prescriber to the need for continued home monitoring and supplies, including the following information pertinent to the child's circumstances:
(a) For a child who is technology-dependent, documentation that the equipment or service on which the child depends is still necessary and is still being used (evidenced, for example, by a copy of a recent clinician follow-up report or home health agency visit report noting equipment and services);
(b) For a child who is not technology-dependent, documentation of recent, clinically significant apnea or bradycardia (evidenced, for example, by a copy of recent monitor data or a recent pneumogram showing instances of apnea or bradycardia) or documentation of a recent emergency department visit or hospital admission for an ALTE; and
(c) For a child whose sibling died of SIDS, the birth and death dates of the sibling (for the purpose of indicating whether the child is currently younger than the sibling was at the time of death); and
(ii) Either a full report of the information recorded by the apnea monitor during the initial rental period or a summary of the information accompanied by a statement that a full report is available on request.
(2) Payment for an apnea monitor includes professional time, data recording, transmission or printing, maintenance, and supplies.
(3) The default certificate of medical necessity (CMN) form is the ODM 02900, "Certificate of Medical Necessity: Apnea Monitors" (rev. 7/2018).
(B) Constraints and limitations.
(1) The following diagnoses, conditions, or circumstances are not by themselves indications for monitoring:
(a) Seizures or seizure disorders in the absence of ALTEs;
(b) Uncomplicated hydrocephalus;
(c) Developmental disability;
(d) Terminal illness;
(e) Congenital heart defect, with or without associated arrhythmia;
(f) History of apnea in immediate siblings;
(g) History of monitor use with immediate siblings;
(h) History of apnea or SIDS in family members other than immediate siblings;
(i) Parental anxiety or family request for a monitor; and
(j) Need to monitor blood oxygen saturation.
(2) Apnea monitoring in the home does not include pneumograms. A medically necessary pneumogram is ordered by a qualified prescriber and is based on the presence of appropriate symptoms or conditions. No payment will be made for a pneumogram that is used as a screening test in the absence of appropriate symptoms or conditions.
Last updated January 2, 2024 at 8:57 AM
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