Clinical UM Guideline |
Subject: Back-Up Ventilators in the Home Setting | |
Guideline #: CG-DME-26 | Publish Date: 10/01/2024 |
Status: Reviewed | Last Review Date: 08/08/2024 |
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 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.
When services may be Medically Necessary when criteria are met:
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) |
E0467 | Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions |
E0468 | Home ventilator, dual-function respiratory device, also performs additional function of cough stimulation, includes all accessories, components and supplies for all functions [when specified as used with a non-invasive interface] |
|
|
| Note: HCPCS modifier ‘-TW’ may be used with the above procedure codes to indicate ‘back-up equipment’. |
|
|
ICD-10 Diagnosis |
|
| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria for a back-up (second) device are not met.
Discussion/General Information |
Mechanical ventilation may be defined as a life support system designed to replace or support normal ventilatory lung function (AARC, 2007). There are a myriad of medical conditions that may cause an individual to require the use of mechanical ventilation for either a short-term or long-term basis. Ventilators can be categorized as either invasive or noninvasive. Invasive mechanical ventilation is defined as the delivery of positive pressure to the lungs via an endotracheal or tracheostomy tube. It is most often used to fully or partially replace the function of spontaneous breathing and gas exchange. Noninvasive ventilation (NIV) may be required part of the time and is delivered through an alternative interface such as a face mask (Hyzy, 2021).
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 consistent with 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:
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 | 08/08/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Revised References section. |
| 06/28/2024 | Updated Coding section, added E0468. |
Revised | 08/10/2023 | MPTAC review. Reformatted bullets to alphanumeric. Updated Reference section. |
Reviewed | 08/11/2022 | MPTAC review. Updated Discussion and Reference sections. |
Reviewed | 08/12/2021 | MPTAC review. Updated Discussion/General Information and References sections. |
Revised | 08/13/2020 | MPTAC review. Updated MN formatting in the Clinical Indications section. Removed written version of number and maintained numeric value in MN Clinical Indications section. Updated Description and References sections. Reformatted Coding section. |
Reviewed | 08/22/2019 | MPTAC review. References were updated. |
| 12/27/2018 | Updated Coding section with 01/01/2019 HCPCS changes; added E0467. |
Reviewed | 09/13/2018 | 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 |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.
© CPT Only – American Medical Association