Clinical UM Guideline

 

Subject: Back-Up Ventilators in the Home Setting
Guideline #:  CG-DME-26 Publish Date:    10/17/2018
Status: Reviewed Last Review Date:    09/13/2018

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

 

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’.

 

 

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 July 26, 2018.
  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 July 26, 2018.
  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. McKim DA, Road J, Avendano M, et al. A Canadian Thoracic Society (CTS) Clinical Practice Guideline: Home Mechanical Ventilation.  Can Respir J. 2011; 18(4):197-215. Available at: http://muscle.ca/wp-content/uploads/2012/11/2011_CTS_HMV_Executive_Summary.pdf. Accessed on July 26, 2018.
  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

Reviewed

09/13/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. References were updated.

Reviewed

11/02/2017

MPTAC review. The document header wording was updated from “Current Effective Date” to “Publish Date.” References were updated.

Reviewed

11/03/2016

MPTAC review. References were updated.

Reviewed

11/05/2015

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