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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 2.2
Infantile Apnea Cardiorespiratory Monitor
Issue Date:  December 4, 1987
Authority:  32 CFR 199.4(d)(3)(ii), 10 United States Code (USC) Section 1079(a)(15)
Revision:  C-1, March 10, 2017
Level II Code E0618 and E0619
Apnea refers to abnormal cessation of air exchange. Infantile apnea is thought to be one of the pediatric disorders of respiratory control. Abnormalities that have been identified in infants with idiopathic apnea include prolonged episodes of apnea during sleep, often associated with bradycardia; an increased incidence of upper airway obstruction; a high density of short apneic episodes during sleep; excessive periodic breathing during sleep and diminished arousal and ventilatory responses to induced hypercapnia and hypoxemia.
3.1  Use of a cardiorespiratory monitor, with or without a trend-event recorder, may be covered for in-home diagnostic data-collection or in-home clinical management of a condition or suspected condition, which places the beneficiary at extraordinary risk of life threatening cardiorespiratory complications for which 24-hour per day observation would otherwise be clinically indicated.
3.2  Associated services and items are covered in conjunction with a covered cardiorespiratory monitor.
3.3  Other applicable policy. Equipment cost-share is subject to the provisions of the Durable Medical Equipment (DME)/Durable Equipment (DE) Basic Program.
4.1  Screening Pneumogram. A 12- to 24-hour pneumogram (recordings of heart rate and thoracic impedance) accomplished solely as a predictive test for Sudden Infant Death Syndrome (SIDS) risk or life-threatening apnea risk.
4.2  A back-up electrical system or any alteration to the beneficiary’s living space.
4.3  Any separate charge for the availability of medical, technical, or counseling assistance.
4.4  Equipment which monitors only respiration or cardiac function.
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