Clinical UM Guideline


Subject:Back-Up Ventilators in the Home Setting
Guideline #:  CG-DME-26Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

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

This clinical UM guideline 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.

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 
E0450Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
E0460Negative pressure ventilator; portable or stationary
E0461Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
E0463Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
E0464Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
  
 Note:  HCPCS modifier '-TW' may be used with the above procedure codes to indicate 'back-up equipment'.
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 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 3, 2013.
  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 3, 2013.
  3. 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.
  4. 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 3, 2013.
  5. 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

History

Status

Date

Action

Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review.  No change to criteria.  References were updated.
Reviewed11/08/2012MPTAC review.  No change to criteria.  References were updated.
Reviewed11/17/2011MPTAC review.  No change to criteria.  References were updated.
Reviewed11/18/2010MPTAC review.  No change to criteria.  References were updated.
Reviewed11/19/2009MPTAC review.  No change to criteria.  References were updated.
Reviewed11/20/2008MPTAC review.  No change to criteria.  References were updated.
Reviewed11/29/2007MPTAC review.  No change to criteria.  References were updated.
Reviewed12/07/2006MPTAC review.  No change to guideline criteria.  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