CG-DME-26 Back-Up Ventilators in the Home Setting

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).

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:

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.

When services are Not Medically Necessary:
For the procedure codes listed above when criteria for a back-up (second) device are not met.

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.

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.

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Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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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

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

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