Prior Authorization : Oxygen and Respiratory Equipment

Apnea Monitor

An apnea monitor is a device used to monitor respirations, heart rate, or both, and alert the caregiver when these are outside the limits set by the physician.

The apnea monitor rental includes the alarm, cables, electrodes, and lead wires. These items are not separately reimbursed.

Key elements for the approval of PA requests for apnea monitors are as follows:

• Documentation must include the alarm settings for the apnea monitor.
• For members up to the age of six months, documentation must include one of the following:
  • Documented family history of apnea, SIDS, or near-miss SIDS.
  • One or more incidences of apnea within the past six months, as well as the intervention and outcome that occurred for each incident. Documentation must also include the response plan when the monitor sounds an alarm.
  • Presence of an artificial airway and the type of required assisted breathing device or ventilator, if used.
• For members over the age of six months, documentation must include all of the following:
  • Presence of an artificial airway and the type of required assisted breathing device or ventilator, if used, including the frequency and amount of time the apnea monitor is used as ordered by the physician.
  • One or more incidences of apnea within the past six months, the response plan when the monitor sounds an alarm, as well as the intervention and outcome which occurred for each incident; abnormal blood gases; or an event recording (histogram) showing abnormalities if the absence of apnea is noted within the past six months.
  • For recurrent apnea, evidence of abnormal blood gases or a clogged airway and information on what has been used to prevent or decrease episodes of a clogged artificial airway.
• Apnea monitors are rarely indicated for members four years of age or over.