Apnea Monitors, Pediatric


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Apnea Monitors, Pediatric

Question

Reply or required information

Has the infant had an apparent life threatening event (ALTE) defined as an episode that is frightening to observe and is characterized by some combination of:

Apnea, Color change, Marked change in muscle tone, Choking, Gagging


Select from drop down:

Yes or No

If yes, please describe how long the episode lasted and if associated with bradycardia (heart rate less than 80 beats per minute) and cyanosis




Does the infant have a tracheostomy or anatomic abnormality that makes them vulnerable to airway compromise?

Select from drop down:

Yes or No

Does the infant have a neurologic or metabolic disorder effecting respiratory control?

Select from drop down:

Yes or No

Does the infant have chronic lung disease (i.e. bronchopulmonary dysplasia) requiring

Supplemental oxygen,

Continued positive airway pressure, or

Mechanical ventilation

Select from drop down:

Yes or No

Is the infant a sibling of sudden infant death (SID) victim?

Select from drop down:

Yes or No

Have the parents and other caregivers been trained in observation of the infant, operation of the monitor and infant cardio-pulmonary resuscitation (CPR)?

Select from drop down:

Yes or No

REAUTHORIZATION—above questions and:

Does the pediatric home apnea monitoring event recording include respiratory rate, pattern and heart rate over a 30 day period?

Select from drop down:

Yes or No

Has the physician established a plan for periodic review and termination?

Select from drop down:

Yes or No

Date range:




Anticipated discharge date:




UV/Light therapy


Question

Reply or required information

Why does the patient require UV/Light therapy?






Bath/Shower Chair


Question

Reply or required information

What reason does the patient require a Bath/Shower chair?






Bed Cradle



Question

Reply or required information

Is a bed cradle needed to prevent contact with bed coverings?

Select from drop down:

Yes or No


BiPAP


Question

Reply or required information

Is this a request for BiPAP or auto-adjusting CPAP (APAP, DPAP)? Specify device




Does the patient have a clinical disorder characterized as a restrictive thoracic disorder?

Select from drop down

Yes, No, orNA

If yes, does the patient have either a progressive neuromuscular disease or severe thoracic cage abnormality? If yes, specify




If available, what is the patient’s arterial blood gas (done while the patient is awake on their usual FIO2)?




What is the patient’s oxygen saturation (based on the patient’s sleep oximetry while breathing the patient’s usual FIO2)?




If they have a progressive neuromuscular disease, is their forced vital capacity < than 50%, or their maximal inspiratory pressure less than 60cm H20?



Does chronic obstructive pulmonary disease not contribute significantly to the patient’s pulmonary limitation?

Select from drop down

Yes or No

Does the patient have COPD?

Select from drop down

Yes, No, or NA

If yes, is the patient’s arterial blood gas PaCO2, (done while awake and breathing the patient’s usual FIO2) > than or equal to 52 mm Hg?

Select from drop down

Yes or No

Does the patient’s sleep oximetry demonstrate oxygen saturation < than or equal to 88% for at least five continuous minutes, done while breathing oxygen at 2 LPM or the patient’s usual FIO2 (whichever is higher)?

Select from drop down

Yes or No

Prior to initiating therapy with BiPAP, has Obstructive Sleep Apnea (OSA) and treatment with a continuous positive airway pressure device (CPAP) been considered and ruled out?

Select from drop down

Yes or No

Does the patient have Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA)?

Select from drop down

Yes, No, or NA

If yes, what is the AHI?




Are the central apneas/hypopneas > than 50% of the total apneas/hypopneas?

Select from drop down

Yes or No

Are the central apneas or hypopneas > than or equal to 5 times per hour?

Select from drop down

Yes or No

Does the patient have symptoms of either excessive sleepiness or disrupted sleep?

Select from drop down

Yes or No

Prior to initiating therapy to treat Central Sleep Apnea or Complex Sleep Apnea, has the patient had a complete facility based attended polysomnogram confirming the diagnosis?

Select from drop down

Yes or No

Has CPAP been ruled out as effective therapy if either CSA or OSA is a component of the initially observed sleep-associated hypoventilation?

Select from drop down

Yes or No

Has significant improvement of sleep associated hypoventilation been noted using BiPAP, APAP or DPAP while breathing the patient’s usual FiO2 on the settings prescribed for home use?

Select from drop down

Yes or No

Prior to initiating BiPAP therapy for the patient’s medical condition, has the patient tried a CPAP device and was found to be ineffective during the initial 3 month trial?

Select from drop down

Yes or No

Was a CPAP device used for > than 3 months and then found to be ineffective?

Select from drop down

Yes or No

Has the patient failed a previous 3 month trial of PAP therapy (including patient non compliance)?

Select from drop down

Yes or No

If the patient has failed, have they now had a face to face clinical re-evaluation by the treating physician to determine the cause of the failure to respond to PAP therapy?

Select from drop down

Yes or No

Did they have a repeat sleep test in a facility-based setting (Type 1 study)?

Select from drop down

Yes or No

Is BiPAP without a back up rate feature, requested to treat obstructive sleep apnea because CPAP has been tried and proven ineffective or not tolerated?

Select from drop down

Yes or No

Has the referral source been instructed to fax the diagnostic sleep study (including AHI, or RDI, and titration if done) along with the physician’s prescription?

Select from drop down

Yes or No

Medicare Advantage Members-See below




Is BiPAP without a back up rate feature, requested to treat obstructive sleep apnea because CPAP has been tried and proven ineffective or not tolerated?




How was the diagnosis of obstructive sleep apnea (OSA) determined, specify:

Polysomnogram (Type I study) performed in a facility-based laboratory, or

Home Sleep Test (HST) (Type II or III, IV, Other)




If performed in the facility, does the study include sleep staging, a FOG, FMG, FCG testing?




Does the study include airflow, respiratory effort and oxygen saturation by oximetry?




For home sleep testing:

What device was used

What is the FCG

Heart rate

Oxygen saturation




Has the referral source been instructed to fax the diagnostic sleep study, other testing as noted in either the facility or home, along with the physician’s prescription?

Select from drop down

Yes or No

REAUTHORIZATION—see below

Has the patient been using the device for 3 months?

Select from drop down

Yes or No

When was the patient seen by the physician for a clinical re evaluation after starting PAP therapy?




Has the physician determined the patient is benefitting from PAP therapy?

Select from drop down

Yes or No

Per download from the device, Smart Card or other data card, how many hours per night in the patient using the device?




During the last 30 days of the 3 month trial period how many nights did the patient use the device?




Does the physician’s re evaluation include documentation of improvement in subjective symptoms? If yes, specify




Blood Glucose Monitors


Question

Reply or required information

Has the patient’s physician submitted a Certificate of Medical Necessity?




Is the patient being treated for diabetes?




Has the ordering physician prescribed the monitor and accessories needed, including testing frequency?




Who is capable of being trained in using the glucometer and in monitoring the patient?




Is the device for home use?




What items are ordered?




Based on the patient’s medical condition, how often is the patient to test?




Is the physician’s order signed and dated?




What is the start date of the order? (required if the start date is different than the signature date)




Is the patient insulin or non-insulin dependent?




Is a glucometer with special features requested?



Has the physician certified the patient has a severe visual impairment (defined as best corrected visual acuity is 20/200 or worse) that prevents the use of a standard blood glucose monitor?




Has the physician certified that the patient has a manual dexterity impairment requiring the use of a special features glucometer?




If yes, what is the nature of the physical impairment? (request for a special feature glucometer for patients with manual dexterity impairments is not dependent upon a visual impairment)




Is this a request for a replacement glucometer?




Why does the patient need a replacement?




Medicare Advantage Members-above questions and:

Has the patient or caregiver successfully completed or is scheduled to begin to train to use the monitor, test strips, and lancing devices?




Is the patient or caregiver capable of using the test results to assure the patient has appropriate glycemic control?




If a special feature glucometer is requested, does the patient have a severe visual impairment (i.e. best corrected visual acuity of 20/200 or worse in both eyes)?




Has the patient’s testing frequency order changed, if so, has this been verified by physician order?






Breast Pump


Question

Reply or required information

What reason does the patient require a Breast Pump?




Will there be a separation between the mother and baby?




What type of pump is being requested?






Cold Therapy


Question

Reply or required information

What reason does the patient require a cold therapy?






Conductive Garment


Question

Reply or required information

Is the conductive garment used with a TENS unit?

Select from drop down

Yes or No

  1. Is the conductive garment FDA approved?

Select from drop down

Yes or No

  1. Has the physician prescribed the use of a conductive garment?

Select from drop down

Yes or No

Does the patient have a large area or multiple sites to be stimulated and the stimulation would have to be delivered so frequently that pain cannot be managed by using conventional electrodes, adhesive tapes or lead wires?

Select from drop down

Yes or No

Is the patient’s chronic intractable pain located in an area that is inaccessible with the use of conventional electrodes?

Select from drop down

Yes or No

Does the patient have a medical condition (i.e., skin condition) that prevents the use of conventional electrodes?

Select from drop down

Yes or No

Does the patient require electrical stimulation beneath a cast?

Select from drop down

Yes or No


Continuous Glucose Monitoring (CGM)



Question

Reply or required information

Does the patient have Type I diabetes or insulin dependent Type II diabetes? specify



Has the patient had failed control despite adherence to a treatment regime which includes:

4 or more finger sticks per day, or

3 or more insulin injections per day, and

Prior use of the 72 hour monitor

Select from drop down:

Yes or No

Does the patient have recurrent, unexplained, severe, symptomatic episodes of hypoglycemia that puts the patient or others at risk?

  1. What are the blood glucose levels?

Select from drop down:

Yes or No

Is the patient insulin dependent and pregnant whose diabetes is poorly controlled with any of the following clinical situations (select all that apply):

Unexplained hypoglycemic episodes

Hypoglycemic unawareness

Suspected postprandial hyperglycemia

Recurrent diabetic ketoacidosis




Does the insulin dependent pregnant patient do multiple daily insulin injections with frequent monitoring? specify

Select from drop down:

Yes or No

What model of CGM is requested?




Is the model requested an external insulin pump with wireless communication to a compatible continuous glucose monitoring sensor/transmitter?

Select from drop down:

Yes or No

Is this to replace existing functioning equipment to upgrade to wireless technology?

Select from drop down:

Yes or No


Commodes


Question

Reply or required information

What type of commode is being requested (i.e., 3-1 or drop arm), (3-1 commode has a 300-lb. maximum weight limit / drop arm commode has up to a 300-lb. maximum weight limit.)?




Height




Weight




Ambulatory status




Is the patient confined to a bed, room, or one floor of their home with out a bathroom?





Toilet Seat



Question

Reply or required information

What reason does the patient require a raised toilet seat?



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