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:

  1. The individual cannot maintain spontaneous ventilations for 4 or more consecutive hours; and
  2. The individual lives in an area where a replacement ventilator cannot be provided within 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:

  1. 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.

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:

  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: https://www.aarc.org/wp-content/uploads/2014/08/08.07.1056.pdf. Accessed on July 2, 2024.
  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 2, 2024.
  3. Centers For Medicare & Medicaid Services. Noninvasive positive pressure ventilation in the home. Available at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/id108TA.pdf. Accessed on July 2, 2024.
  4. Hyzy RC, McSparron JI. UpToDate. Overview of initiating invasive mechanical ventilation in adults in the intensive care unit. Available at: https://www.uptodate.com/contents/overview-of-initiating-invasive-mechanical-ventilation-in-adults-in-the-intensive-care-unit?search=invasive%20ventilation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4167959455. Accessed on July 2, 2024.
  5. King AC. Respiratory Care. Long-term home mechanical ventilation in the united states. June 2012. Available at: https://rc.rcjournal.com/content/57/6/921. Accessed on July 2, 2024.  
  6. 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.
  7. 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.
  8. 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://downloads.hindawi.com/journals/crj/2011/139769.pdf. Accessed on July 2, 2024.
  9. 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

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

 


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