CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Home Apnea Monitor Coverage

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This policy governs Medicaid coverage, documentation, prior authorization, and continued rental of home apnea monitors for infants. Initial coverage is available for specified apnea or desaturation conditions for up to six months, with prior authorization and additional documentation required for continued coverage.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyHome Apnea Monitor Coverage

Policy CodePolicy N/A

Change TypeMaterial policy update

Effective DateMarch 1, 2007

Next Review DateN/A

Key ActionObtain prior authorization and submit continued-coverage documentation for rental beyond six months.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for infants with siblings who were victims of sudden infant death syndrome (SIDS) were removed.

A continued coverage section was added for coverage beyond the initial six-month rental period.

Documentation requirements were added for an ordering prescription and a physician or practitioner examination within 90 days of the service authorization start date.

20 secQualifying apnea duration

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CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Home Apnea Monitor Coverage

Customize your policy alerts

Sign up for all North Dakota Department of Health & Human Services policy alerts

Know when North Dakota Department of Health & Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyHome Apnea Monitor Coverage

Policy CodePolicy N/A

Change TypeMaterial policy update

Effective DateMarch 1, 2007

Next Review DateN/A

Key ActionObtain prior authorization and submit continued-coverage documentation for rental beyond six months.

SourceLink

POLICY UPDATE CHANGES

Coverage criteria for infants with siblings who were victims of sudden infant death syndrome (SIDS) were removed.

A continued coverage section was added for coverage beyond the initial six-month rental period.

Documentation requirements were added for an ordering prescription and a physician or practitioner examination within 90 days of the service authorization start date.

20 secQualifying apnea duration

Oxygen desaturation threshold

6 monthsInitial rental period

90 daysExamination timeframe

2 monthsPrior-use review period

Not coveredSIDS-risk-only use

Coverage Criteria

Initial rental coverage

Covered for rental up to six months when ANY of the following is met:

Qualifying initial-coverage condition

Significant apnea: The infant has significant apnea.20 seconds or longer
Mild to moderate apnea with desaturation: The infant has mild to moderate apnea and desaturates below 90%.Below 90%
Periodic breathing with desaturation: The infant has periodic breathing with desaturation below 90%.Below 90%

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Continued coverage

Continued coverage beyond six months requires prior authorization and documentation of ALL of the following:

Continued coverage requirements

Prior authorization: Additional months of coverage must be prior authorized.Beyond the initial six-month period
Recent apnea frequency: The physician or practitioner documents the number of apnea episodes during the previous two-month period of use.Previous two months
Significant alarms: The infant continues to have significant alarms, and the alarm log is kept on file.Ongoing

Home apnea monitors used for infants who have siblings who were victims of sudden infant death syndrome (SIDS) are not covered.

Home apnea monitoring for this situation is not recommended by the American Academy of Pediatrics and has not been proven to prevent sudden unexpected deaths in infants.

Clinical Thresholds and Timing

Significant apnea

Qualifying duration20 seconds or longer

Oxygen desaturation

Qualifying oxygen saturationBelow 90%

Physician or practitioner examination

Required examination timingWithin 90 days of the service authorization start date

Provider Actions and Authorization

Prior Authorization

Prior Authorization After Six Months

Prior authorization is required for coverage beyond the initial six-month rental period. Submit the authorization request with the physician/practitioner documentation required to support continued medical necessity.

Applies to each additional month after the initial six-month period.

Prior Authorization

Check Code-Specific Authorization Requirements

Reference the Look-Up Tool to determine whether the specific apnea-monitor code requires Service Authorization.

Check code-specific Service Authorization requirements before billing or requesting coverage.

Unsupported block type: documentation

Policy Background

This policy addresses Medicaid coverage of home apnea monitors for infants with significant apnea, apnea accompanied by oxygen desaturation, or periodic breathing accompanied by oxygen desaturation. Initial coverage is available as a rental for up to six months; continued use requires prior authorization and documentation supporting ongoing symptomatic apnea, significant monitor alarms, recent testing, and the estimated duration of continued need.

Medical Necessity

Initial apnea monitor medical necessity

Initial rental coverage requires at least one qualifying infant apnea or desaturation condition:

Initial medical necessity

The infant has significant apnea.20 seconds or longer
The infant has mild to moderate apnea and desaturates below 90%.Below 90%
The infant has periodic breathing with desaturation below 90%.Below 90%

Continued apnea monitor medical necessity

Rental and Purchase Rules

Equipment	Rental or purchase rule	Coverage period and conditions
Apnea monitor
Rental
Covered for rental up to six months when at least one qualifying condition is present: significant apnea lasting 20 seconds or longer; mild to moderate apnea with oxygen desaturation below 90%; or periodic breathing with oxygen desaturation below 90%.

Equipment	Rental or purchase rule	Requirements for additional coverage
Apnea monitor
Rental
Coverage beyond the initial six-month period requires prior authorization and physician or practitioner documentation of the number of apnea episodes during the previous two months, continued significant alarms with the log kept on file, unresolved symptomatic apnea, tests and test results from the previous two months, the estimated additional time the monitor will be needed, and any other pertinent information.

Documentation Requirements

Documentation Required

Document the order and clinical need

The prescription must be from the ordering physician or practitioner. Document the apnea-monitor criteria and the projected length of time the equipment will be needed.

Documentation Required

Complete the required examination

Ensure that the physician or practitioner examination occurs within 90 days of the service authorization start date.

Documentation Required

Support continued monitor use

For continued coverage, document the number of apnea episodes during the previous two-month period of use, continued significant alarms with the alarm log kept on file, unresolved symptomatic apnea, tests and test results from the previous two-month period, and the estimated additional length of time the monitor will be needed.

Include any additional pertinent information the physician may wish to provide.

Not Covered

Apnea monitors used for infants who have siblings who were victims of sudden infant death syndrome (SIDS) are not covered.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyHome Apnea Monitor Coverage

Policy CodePolicy N/A

Change TypeMaterial policy update

Effective DateMarch 1, 2007

Next Review DateN/A

Key ActionObtain prior authorization and submit continued-coverage documentation for rental beyond six months.

SourceLink

On This Page

Unresolved symptomatic apnea: The physician or practitioner documents unresolved symptomatic apnea.Present

Recent testing: The physician or practitioner documents tests and test results performed during the previous two-month period of use.Previous two months

Expected duration of need: The physician or practitioner documents the estimated additional length of time the monitor will be needed.Estimated additional period

Additional pertinent information: The physician or practitioner provides any additional pertinent information.As applicable

Documentation Required

Continued-Coverage Documentation

For continued coverage, the physician/practitioner must document the infant’s ongoing need using evidence from the previous two months of monitor use.

Number of apnea episodes during the previous two-month period of use.
Evidence that the infant continues to have significant alarms; the alarm log must be kept on file.
Unresolved symptomatic apnea.
Tests performed and the results of tests performed during the previous two-month period of use.
Estimated additional length of time the monitor will be needed.
Any other pertinent information the physician/practitioner wishes to provide.

Denial Risk

Non-Qualifying Indication or SIDS-Risk-Only Use

Coverage is not available when the qualifying medical-necessity criteria are absent or when the monitor is used only because an infant has a sibling who was a victim of sudden infant death syndrome (SIDS).

At least one qualifying condition must be present: significant apnea lasting 20 seconds or longer; mild-to-moderate apnea with desaturation below 90%; or periodic breathing with desaturation below 90%.
Home apnea monitoring for SIDS-risk-only use is not covered and has not been proven to prevent sudden unexpected deaths in infants.

Denial Risk

Insufficient Continued-Coverage Documentation

Missing documentation supporting continued use may result in denial or non-coverage for months beyond the initial six-month rental period.

Do not request continued coverage without the required prior authorization and physician/practitioner evidence from the previous two months.
Ensure the apnea-episode count, alarm log, unresolved symptomatic apnea, testing and results, estimated duration of additional need, and other pertinent information are documented.

Continued rental requires prior authorization and ALL of the following evidence of ongoing need:

Continued medical necessity

Prior authorization: Additional months of coverage are prior authorized.Beyond the initial six-month period
Ongoing symptomatic need: The infant continues to have significant alarms and unresolved symptomatic apnea.Ongoing
The alarm log must be kept on file.
Recent apnea records: The number of apnea episodes during the previous two-month period of use is documented.Previous two months
Recent testing: Tests and test results performed during the previous two-month period of use are documented.Previous two months
Expected duration of need: The estimated additional length of time the monitor will be needed is documented.Estimated additional period
Additional pertinent information: Any additional pertinent information the physician or practitioner wishes to provide is included.As applicable