Section 427.442 - Clinical Requirements: Respiratory Therapy Equipment - Apnea Monitor(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).