Apnea Monitors, Pediatric

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
a)Is the conductive garment FDA approved? / Select from drop down
Yes or No
b)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?

CPAP

Question / Reply or required information
Is this a request for a CPAP device--Continuous Positive Airway Pressure Device (includes C-Flex and CPAP with expiratory pressure relief (EPR), specify device
What comorbidities does the patient have?
How was the diagnosis of obstructive sleep apnea (OSA) determined, specify: (NA for Medicare Advantage members)
Polysomnogram (Type I study) performed in a facility-based laboratory, or
Home Sleep Test (HST) (Type II or III)
Does the patient have: Excessive daytime sleepiness or drowsiness, Impaired cognitive ability
Mood disorders, Insomnia
If yes, please specify
Does the patient have Hypertension, Ischemic heart disease, Stroke
If yes, please specify
What is the AHI (Apnea-Hypopnea Index) or RDI (Respiratory Disturbance Index)?
Is the request for CPAP for a pediatric patient?
If, yes, does the patient have excessive daytime sleepiness, behavior problems, or hyperactivity?
If yes, please specify
What is the AHI?
Has a titration study been done to achieve optimal CPAP pressure to eliminate sleep related breathing events in all stages and positions of sleep?
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?
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 C-Clex or CPAP with EPR ordered over standard CPAP to improve patient comfort and compliance? / Select from drop down
Yes or No
Medicare Advantage Members-above questions and:
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?
REAUTHORIZATION—see below
Has the patient been using the CPAP device for 3 months?
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?
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 of OSA? If yes, specify
Does the re evaluation include documentation showing objective data related to patient adherence to the PAP therapy? / Select from drop down
Yes or No
Has the physician determined that use of C-Clex or CPAP with EPR over standard CPAP would improve patient compliance? / Select from drop down
Yes or No

CPAP/BIPAP Mask and Supplies

Question / Reply or required information
Has the patient previously qualified for a CPAP or BIPAP? / Select from drop down:
Yes
No
Does the patient have a CPAP/BIPAP currently in the home? / Select from drop down:
Yes
No

Continuous Passive Motion Device (CPM)

Question / Reply or required information
Did the patient have a total knee replacement (either unilateral or bilateral)? / Select from drop down:
Yes or No
Did the patient have an anterior cruciate ligament (ACL) reconstruction (either bilateral or unilateral)? / Select from drop down:
Yes or No
Is CPM ordered for treatment of all other applications of the knee (e.g. repairs of cartilaginous defects such as autologous chondrocyte transplantation)? / Select from drop down:
Yes or No
Is CPM ordered in the home setting for treatment of all other joints such as hip, shoulder, elbow, metacarpals, interphalangeal joints, or metatarsals? / Select from drop down:
Yes or No
Was CPM applied immediately after surgery? / Select from drop down:
Yes or No
What settings are ordered (range of motion, speed)?
REAUTHORIZATION –above questions and:
Has the patient received CPM therapy for 14 days post operatively yet? / Select from drop down:
Yes or No
What is the current range of motion tolerated by the patient?
Date range
Anticipated discharge date

Cushion-Gel