Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.09-042 - Prosthetics Update Transmittal #70

Current through Register Vol. 49, No. 6, June, 2024
Section
			 II
Prosthetics
212.201
			 (DME)
Apnea Monitors for Infants Under Age 1
Arkansas Medicaid covers apnea monitors only for infants less
				than one (1) year of age. Use of the apnea monitor must be medically necessary
				and prescribed by a physician.
A primary care physician (PCP) is not required until an
				infant's Medicaid eligibility has been determined. No PCP referral for medical
				services is required for retroactive eligibility periods.
For the initial certification, the prescribing physician must
				sign form DMS-679A titled Prescription and Prior Authorization Request for
				Medical Equipment Excluding Wheelchairs and Wheelchair Components. The
				physician's signature must be an original, not a stamp. When an apnea monitor
				is prescribed during a hospital discharge, the physician ordering the apnea
				monitor must be in consultation with a neonatologist or pulmonologist.
As necessary, the primary care physician's (PCP's) name and
				provider number must also be indicated on DMS-679A titled Prescription and
				Prior Authorization Request for Medical Equipment Excluding Wheelchairs and
				Wheelchair Components. The PCP's signature is not required on the initial
				certification but he or she must sign all re-certifications.
A prior authorization request for an apnea monitor must be
				submitted to AFMC on form DMS-679A titled Prescription and Prior Authorization
				Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components.
				View or print form DMS-679 and instructions for completion. View or print AFMC
				contact information.
Compliance, and the download monitor report, must accompany the
				request for continued use of the apnea monitor following the initial sixty-day
				time period.
Prior authorization is not required for the initial sixty-day
				period of use of the monitor. If the apnea monitor is needed longer than an
				initial sixty-day period, prior authorization is required.
A new prescription, documentation of compliance during the
				initial sixty-day period and proof of medical necessity for the continuation of
				monitoring are required.
The following criteria, established by the
American
				Academy of Pediatrics
, are to be used to evaluate the need for an
				apnea monitor after the initial sixty-day period:
A. Evidence exists that preterm infants are
			 at greater risk of extreme apnea episodes until approximately 43 weeks post
			 conceptual age. Monitoring may be indicated until 43 weeks post conceptual age
			 unless extreme episodes persist beyond that time. Home monitoring may be
			 indicated for other selected groups of infants, as well.
B. Home cardiorespiratory monitoring may be
			 warranted for premature infants who are at high risk of recurrent episodes of
			 apnea, bradycardia, and hypoxemia after hospital discharge.
The use of home cardiorespiratory monitoring in this population
				should be limited to approximately 43 weeks post conceptual age or after the
				cessation of extreme episodes, whichever comes last.
C. Home cardiorespiratory monitoring may be
			 warranted for infants who are technology dependent (tracheostomy, supplemental
			 oxygen, continuous positive airway pressure, etc.), have unstable airways, have
			 rare medical conditions affecting regulation of breathing or have symptomatic
			 chronic lung disease.
In many of these cases, the use of pulse oximetry monitoring is
				superior and preferred over simple cardiorespiratory monitoring.
D. Other infants who may benefit
			 from home cardiorespiratory home monitoring include:
1. Infants who have experienced an apparent
			 life-threatening event (ALTE)
An ALTE is defined as "an episode that is frightening to the
				observer and 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."
2. Infants with tracheotomies or anatomic
			 abnormalities that may compromise their airway
3. Infants with metabolic or neurological
			 abnormalities affecting respiratory control
4. Infants with chronic lung disease of
			 prematurity (bronchopulmonary dysplasia, BPD), especially those requiring some
			 form of respiratory support
E. Parents or caregivers must be counseled
			 regarding the purpose of the home cardiorespiratory monitoring and realistic
			 expectations of what it can and cannot contribute to an infant's well being.
1. When monitoring is used in the home,
			 parents and other caregivers must be trained in observation techniques,
			 operation of the monitor, and infant cardiopulmonary resuscitation prior to the
			 use of the monitor.
2. Medical and
			 technical support staff should always be available for direct or telephone
			 consultation.
F.
			 Duration and discontinuation of home cardiorespiratory monitoring
1. When home monitoring is prescribed for
			 apnea/bradycardia in preterm infants, the physician should establish a plan for
			 review of clinical and event (download) data at 43 weeks post conceptual age.
			 If monitoring is to be continued beyond that time, documentation should be
			 provided as to why it should be continued as well as a plan for
			 reevaluation.
2. Infants whose
			 mothers have unsure dates (uncertain post-conceptual age) may be monitored
			 until the infants are at least 43 weeks post conceptual age.
3. When home monitoring is prescribed for
			 indications other than apnea/bradycardia in preterm infants, continuation of
			 monitoring will be reviewed on a case-by-case basis.
4. Discontinuation of home monitoring should
			 be a clinical decision based on a combination of clinical data and
			 cardiorespiratory monitor event data.
5. Decisions regarding discontinuation of
			 home monitoring should NOT be based on single-night pneumograms, which have no
			 proven predictive value in this setting.