Clinical UM Guideline


Subject:  Back-Up Ventilators in the Home Setting
Guideline #:  CG-DME-26Current Effective Date:  01/01/2016
Status:ReviewedLast Review Date:  11/05/2015

Description

This document 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. 

Mechanical ventilation may be defined as a life support system designed to replace or support normal ventilatory lung function (AARC, 1995; updated 2007).

Clinical Indications

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

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.

Coding

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.

HCPCS 
E0465Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
E0466Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
  
 Note: HCPCS modifier '-TW' may be used with the above procedure codes to indicate 'back-up equipment'.
  
ICD-10 Diagnosis 
 All diagnoses
  
Discussion/General Information

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

References

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 7, 2015.
  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: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&NCAId=3&ver=5&NcaName=Air-Fluidized+Beds+for+Pressure+Ulcers&bc=ACAAAAAAIAAA&. Accessed on September 7, 2015.
  3. MacIntyre NR, Epstein SK, Carson S, et al.; National Association for Medical Direction of Respiratory Care (NAMDRC). Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005; 128(6):3937-3954.
  4. 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.
  5. Road J, McKim DA, Avendano M, et al.  A Canadian Thoracic Society (CTS) Clinical Practice Guideline:  Home Mechanical Ventilation. (No date). Available at:  http://www.respiratoryguidelines.ca/sites/all/files/2011_CTS_HMV_Guideline.pdf. Accessed on September 7, 2015.
  6. 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.
Index

Ventilators, Back-up in the Home Setting

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed11/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review. References were updated. Updated Coding section with 01/01/2016 HCPCS changes; removed E0450, E0460, E0461, E0463, E0464 deleted 12/31/2015 and also removed ICD-9 codes..
Reviewed11/13/2014MPTAC review.  References were updated.
Reviewed11/14/2013MPTAC review. References were updated.
Reviewed11/08/2012MPTAC review. References were updated.
Reviewed11/17/2011MPTAC review. References were updated.
Reviewed11/18/2010MPTAC review. References were updated.
Reviewed11/19/2009MPTAC review. References were updated.
Reviewed11/20/2008MPTAC review. References were updated.
Reviewed11/29/2007MPTAC review. References were updated.
Reviewed12/07/2006MPTAC review. References and coding were updated.
New12/01/2005MPTAC initial guideline development.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.  No document
Anthem Southeast (Virginia)08/10/2004Memo 1216Back-Up Ventilators in the Home Setting
WellPoint Health Networks, Inc.  No document