Mechanical ventilation may be defined as a life support system designed to replace or support normal ventilatory lung function (AARC, 1995).

This clinical UM guideline addresses the medically necessary indications for the use of back-up (or second additional) ventilators in the home setting, for use as a "back-up" machine, if needed.

Medically Necessary:

The use of a back-up (second) ventilator in the home setting is considered medically necessary when ALL of the following criteria are met:

• The individual cannot maintain spontaneous ventilations for four (4) or more consecutive hours; and
• The individual lives in an area where a replacement ventilator cannot be provided within two (2) hours.

The use of a back-up (second) ventilator in the home setting is considered medically necessary for the following additional indication, when applicable:

• For individuals who require mechanical ventilation during mobility, as prescribed in their plan of care.

Not Medically Necessary:

The use of a back-up (second) ventilator in the home setting is considered not medically necessary when the above criteria are not met.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

According to the American Association for Respiratory Care (AARC), individuals eligible for invasive long term mechanical ventilation in the home setting require a tracheostomy tube for ventilatory support, but no longer require intensive medical and monitoring services (AARC, 2007).  

The medical necessity criteria for use of back-up ventilators in the home setting are based on the recommendations of the American Association for Respiratory Care (AARC) Clinical Practice Guidelines for Long-term Invasive Mechanical Ventilation in the Home Setting (AARC, 2007).  This document has not been updated since 2007.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Association for Respiratory Care (AARC) Clinical Practice Guideline: Long-term invasive mechanical ventilation in the home. Original publication: Respir Care. 1995; 40(12):1313-1320. 2007 Update with Revisions. Resp Care. 2007; 52(1):1056-1062.  Available at: http://www.rcjournal.com/cpgs/pdf/08.07.1056.pdf.  Accessed on September 15, 2011.
2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Durable Medical Equipment. Reference List NCD #280.1.  Effective September 1986; most recent update: May 5, 2005.  Available at: https://www.cms.gov/medicare-coverage-database/search/search-results.aspx?CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&KeyWord=Durable
   +medical+equipment&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=g
   AAAAAAAAAAA&=&.  Accessed on September 15, 2011.
3. Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the intensive care unit: Report of a consensus conference of the American College of Chest Physicians (ACCP). Chest. 1998; 113(5Suppl):289S-344S.
4. Stuart M, Weinrich M. Protecting the most vulnerable: home mechanical ventilation as a case study in disability and medical care: Report from a National Institutes of Health (NIH) conference. Neurorehabil Neural Repair. 2001; 15(3):159-166.

Ventilators, Back-up in the Home Setting