Clinical UM Guideline
|Subject:||Back-Up Ventilators in the Home Setting|
|Guideline #:||CG-DME-26||Current Effective Date:||01/01/2016|
|Status:||Reviewed||Last Review Date:||11/05/2015|
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).
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.
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.
|E0465||Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)|
|E0466||Home 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'.|
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.
Government Agency, Medical Society, and Other Authoritative Publications:
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.
|Reviewed||11/05/2015||Medical 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..|
|Reviewed||11/13/2014||MPTAC review. References were updated.|
|Reviewed||11/14/2013||MPTAC review. References were updated.|
|Reviewed||11/08/2012||MPTAC review. References were updated.|
|Reviewed||11/17/2011||MPTAC review. References were updated.|
|Reviewed||11/18/2010||MPTAC review. References were updated.|
|Reviewed||11/19/2009||MPTAC review. References were updated.|
|Reviewed||11/20/2008||MPTAC review. References were updated.|
|Reviewed||11/29/2007||MPTAC review. References were updated.|
|Reviewed||12/07/2006||MPTAC review. References and coding were updated.|
|New||12/01/2005||MPTAC initial guideline development.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||No document|
|Anthem Southeast (Virginia)||08/10/2004||Memo 1216||Back-Up Ventilators in the Home Setting|
|WellPoint Health Networks, Inc.||No document|