CSHCN 2009 >32.2.2 Cardiorespiratory (Apnea) Monitors

Prior authorization with documentation of medical necessity is required for diagnoses other than those listed below for infants 4 months of age or younger.

Prior authorization with documentation of medical necessity is required for infants older than 4 months of age.

The rental of procedure code E0619 must be used when billing for recording apnea monitors with the following diagnosis codes:


Diagnosis Code	Description
33700	Idiopathic peripheral autonomic neuropathy, unspecified
33709	Other idiopathic peripheral autonomic neuropathy
4260	Atrioventricular block, complete
42610	Unspecified atrioventricular block
42611	First degree atrioventricular block
42612	Mobitz (type) II atrioventricular block
42613	Other second degree atrioventricular block
4270	Paroxysmal supraventricular tachycardia
4272	Unspecified paroxysmal tachycardia
42789	Other specified cardiac dysrhythmias
53011	Reflux esophagitis
53081	Esophageal reflux
74686	Congenital heart block
7707	Chronic respiratory disease arising in the perinatal period
77081	Primary apnea of newborn
77082	Other apnea of newborn
77083	Cyanotic attacks of newborn
77084	Respiratory failure of newborn
77089	Other respiratory problems after birth
77981	Neonatal bradycardia
77982	Neonatal tachycardia
7850	Tachycardia, unspecified
78603	Apnea
V198	Family history of other conditions

Prior authorization may be given for nonrecording apnea monitors (procedure code E0618) used by ventilator dependent clients.

Documentation must be submitted to the claims contractor. Documentation should include information that supports medical necessity. The documentation must include interpretation of previous apnea monitor downloads, be signed and dated by the physician interpreting the download when the infant has had previous monitoring, and document that the apnea monitor to be rented is capable of recording and storing data. Providers must use the form available in Appendix B, "CSHCN Services Program Authorization Request for Apnea Monitor".

Leads and electrodes that are used with an apnea monitor owned by a client must be authorized. The CSHCN Services Program requires that a physician statement declaring that the client owns the monitor be submitted with the claim.

Electrodes and lead wires for the apnea monitor may be reimbursed separately only if the client owns the monitor.