Other Services
Chapter 8
Section 2.2
Infantile
Apnea Cardiorespiratory Monitor
Issue Date: December 4, 1987
Revision: C-1, March 10, 2017
1.0 HCPCS PROCEDURE CODE
Level II Code E0618
and E0619
2.0 DEFINITION
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.
3.0 POLICY
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.
4.0 EXCLUSIONS
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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