OAR 410-122-0240
Apnea Monitors for Infants


(1)

Indications and limitations of coverage and medical appropriateness:

(a)

For infants less than 12 months of age with documented apnea, or who have known risk factors for life-threatening apnea, the Division may cover home apnea monitors and related supplies for any of the following indications:

(A)

Up to three months for:
(i)
Apnea of prematurity: Sudden cessation of breathing that lasts for at least 20 seconds, is accompanied by bradycardia (heart rate less than 80 beats per minute), or is accompanied by oxygen desaturation (O2 saturation less than 90 percent or cyanosis) in an infant younger than 37 weeks gestational age;
(ii)
Apparent life-threatening event (ALTE): An episode that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging;
(iii)
Documented gastroesophageal reflux disease (GERD) that results in apnea, bradycardia, or oxygen desaturation;
(iv)
Documented prolonged apnea of greater than 20 seconds in duration;
(v)
Documented apnea accompanied by bradycardia to less than 80 beats per minute;
(vi)
Documented apnea accompanied by oxygen desaturation (below 90 percent), cyanosis, or pallor;
(vii)
Documented apnea accompanied by marked hypotonia;
(viii)
When off medication for bradycardia previously treated with caffeine, theophylline, or similar agents;

(B)

Upon discharge from an acute care facility for up to one month post-diagnosis for diagnosis of pertussis with positive cultures;

(C)

As the later sibling of an infant who died of Sudden Infant Death Syndrome (SIDS), until the later sibling is one month older than the age at which the earlier sibling died and remains event-free;

(D)

On a case-by-case basis for:
(i)
Infants with tracheostomies or anatomic abnormalities that make them vulnerable to airway compromise;
(ii)
Infants with neurologic or metabolic disorders affecting respiratory control;
(iii)
Infants with chronic lung disease (bronchopulmonary dysplasia), especially those requiring supplemental oxygen, continuous positive airway pressure, or mechanical ventilation;

(b)

Infant apnea monitors are usually considered medically appropriate for no longer than approximately three months except for specific conditions listed above;

(c)

The rental fee includes all training, instruction, assistance, 24-hour on-call support, and any other needed services for effective use of the apnea monitor, including cardiopulmonary resuscitation training. The durable medical equipment prosthetics orthotics and supplies (DMEPOS) provider is responsible for ensuring delivery of these services;

(d)

The Division may cover related supplies necessary for the effective functioning of the apnea monitor for a three-month period based on the following limitations:

(A)

Electrodes, per pair (A4556) — 3 units;

(B)

Lead wires, per pair (A4557) — 2 units;

(C)

Conductive paste or gel (A4558) — 1 unit;

(D)

Belts (A4649) — 2 units;

(e)

The cost of apnea monitor rental includes the cost of cables;

(f)

The Division does not cover apnea monitors with memory recording (E0619) when the attending physician is monitoring the infant with ongoing sleep studies and pneumograms.

(2)

Coding guidelines: For billing purposes, use diagnosis code 798.0, Sudden Infant Death Syndrome (SIDS), for later siblings of infants who died of SIDS.

(3)

Documentation requirements: Submit the following information with the prior authorization (PA) request:

(a)

Documentation (medical records including hospital records, sleep studies, physician’s progress notes, physician-interpreted report from an apnea monitor with memory recording, etc.) of the episode or episodes that led to the diagnosis;

(b)

An order from the physician who diagnosed the infant as having clinically significant apnea or known risk factors for life-threatening apnea. The physician’s order shall indicate the specific type of apnea monitor (with or without recording feature) and detailed information about the type and quantity of related supplies needed;

(c)

For an apnea monitor with recording feature (E0619), submit documentation that supports why an apnea monitor without recording feature (E0618) is not adequate to meet the medical need;

(d)

When dispensing and billing for an item in Table 122-0240, the provider shall ensure that documentation corroborates that all criteria in this rule are met;

(e)

The DMEPOS provider shall maintain documentation and make it available to the Division upon request.

(4)

Table 122-0240.
[ED. NOTE: Tables referenced are available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0240 — Apnea Monitors for Infants, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0240.

410‑122‑0010
Definitions
410‑122‑0020
Orders
410‑122‑0040
Prior Authorization
410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions
410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients)
410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding
410‑122‑0182
Legend
410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing
410‑122‑0186
Payment Methodology
410‑122‑0188
DMEPOS Rebate Agreements
410‑122‑0200
Pulse Oximeter for Home Use
410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea
410‑122‑0203
Oxygen and Oxygen Equipment
410‑122‑0204
Nebulizer
410‑122‑0205
Respiratory Assist Devices
410‑122‑0206
Intermittent Positive Pressure Breathing
410‑122‑0207
Respiratory Supplies
410‑122‑0208
Suction Pumps
410‑122‑0209
Tracheostomy Care Supplies
410‑122‑0210
Ventilators
410‑122‑0211
Cough Stimulating Device
410‑122‑0220
Pacemaker Monitor
410‑122‑0240
Apnea Monitors for Infants
410‑122‑0250
Breast Pumps
410‑122‑0260
Home Uterine Monitoring
410‑122‑0280
Heating/Cooling Accessories
410‑122‑0300
Light Therapy
410‑122‑0320
Manual Wheelchair Base
410‑122‑0325
Power Wheelchair Base
410‑122‑0330
Power-Operated Vehicle
410‑122‑0340
Wheelchair Options/Accessories
410‑122‑0360
Canes and Crutches
410‑122‑0365
Standing and Positioning Aids
410‑122‑0375
Walkers
410‑122‑0380
Hospital Beds
410‑122‑0400
Pressure Reducing Support Surfaces
410‑122‑0420
Hospital Bed Accessories
410‑122‑0475
Therapeutic Shoes for Diabetics
410‑122‑0510
Osteogenesis Stimulator
410‑122‑0515
Neuromuscular Electrical Stimulator (NMES)
410‑122‑0520
Glucose Monitors and Diabetic Supplies
410‑122‑0525
External Insulin Infusion Pump
410‑122‑0540
Ostomy Supplies
410‑122‑0560
Urological Supplies
410‑122‑0580
Bath Supplies
410‑122‑0590
Patient Lifts
410‑122‑0600
Toilet Supplies
410‑122‑0620
Miscellaneous Supplies
410‑122‑0625
Surgical Dressing
410‑122‑0630
Incontinent Supplies
410‑122‑0640
Eye Prostheses
410‑122‑0655
External Breast Prostheses
410‑122‑0658
Gradient Compression Stockings/Sleeves
410‑122‑0660
Orthotics and Prosthetics
410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses
410‑122‑0678
Dynamic Adjustable Extension/Flexion Device
410‑122‑0680
Facial Prostheses
410‑122‑0700
Negative Pressure Wound Therapy Pumps
410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0240’s source at or​.us