Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 427.000 - Oxygen And Respiratory Therapy Equipment
Section 427.442 - Clinical Requirements: Respiratory Therapy Equipment - Apnea Monitor
Universal Citation: 130 MA Code of Regs 130.427
Current through Register 1531, September 27, 2024
(A) Requirements for Coverage. The Division pays for apnea monitoring for certain infants at high risk for sudden death. A pneumogram or multichannel sleep study is not required, but may serve to document one or more of the following requirements:
(1) infants with one or more
documented severe apparent life-threatening events (ALTEs) requiring
mouth-to-mouth resuscitation or vigorous stimulation;
(2) symptomatic pre-term infants (exhibiting
pathologic apnea or bradycardia associated with cyanosis, marked pallor, or
hypotonia at the time of discharge);
(3) a sibling of two or more victims of
sudden infant death syndrome (SIDS);
(4) a sibling of one SIDS victim, if both the
primary care provider and the parents agree that monitoring is indicated and
agree that if the infant has one or two continuous months without significant
numbers of alarms or episodes of apnea (that is, without requiring vigorous
stimulation or resuscitation) monitoring will be discontinued;
(5) central hypoventilation documented by
oximetry; and
(6) other conditions
in which the infant is at an extraordinarily high risk for sudden death that
monitoring can help prevent.
(B) Reasons for Noncoverage. An apnea monitor shall not be approved for the following:
(1) normal asymptomatic
newborns;
(2) routine monitoring of
asymptomatic pre-term infants; and
(3) when an infant with ALTEs has had one or
two continuous months without significant numbers of alarms or episodes of
apnea, bradycardia, or cyanosis that require vigorous stimulation or
resuscitation. Discontinuance or renewal of services must be documented through
personal observations of professional caregivers at home or through data
captured by a smart monitor and documented by a pediatrician.
(C) Required Documentation. The provider must submit the following documentation for reimbursement for apnea monitoring:
(1) a written prescription pursuant to
130 CMR
427.408;
(2) prior authorization pursuant to
130 CMR
427.409; and
(3) documentation of the medical necessity
for an apnea monitor, consisting of notation in the patient record of
apneicepisodes (see
130 CMR 427.407(D)
and
450.206
). A pneumogram or multichannel sleep study is not required, but may serve to
document one or more of the requirements in 130 CMR 427.442(B).
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