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Date Printed: June 24, 2017: 11:30 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. 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.

09-E0000-55

Original Effective Date: 05/15/16

Reviewed: 04/27/17

Revised: 05/15/17

Subject: Positive Pressure Ventilation in Adults

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

The main function of the respiratory system is to get oxygen into the body and to remove carbon dioxide. When a patient's lungs are no longer able to adequately perform this function mechanical ventilation is used. Most commonly, patients are put on a ventilator when they are in respiratory failure. Respiratory failure is when the patient has a low level of oxygen in the blood, even while receiving oxygen therapy and/or when there is an excessive level of carbon dioxide in the blood There are patients who need assistance from a ventilator even though they still have nearly normal levels of oxygen and carbon dioxide in the bloodstream. This can occur when breathing is very uncomfortable. Patients may be placed on mechanical ventilation because of other serious injuries that require treatment, which may interfere with breathing temporarily.

Noninvasive ventilation differs from invasive ventilation (E0465) using an invasive interface between the patient and ventilator. In the home setting invasive ventilator support is provided via tracheostomy tube. Noninvasive ventilator support uses interfaces such as nasal masks; orofacial masks mouthpieces, nasal pillows, or full-face mask.

The following types of patients can benefit from home mechanical ventilation:

POSITION STATEMENT:

Note: This guideline does not address the use of other respiratory assist devices including BiPAP or CPAP. Positive pressure ventilators can be set up to function in a bi-level mode, and should not be provided when a bi-level device will meet the member’s needs.

Indications for Non-Invasive Positive Pressure Ventilation

A non-invasive positive pressure ventilator (NPPV) meets the definition of medical necessity when the following criteria are met (I-V):

I. The physician documentation includes objective evidence that:

the member’s condition is so severe that the member cannot be successfully managed on a bi-level device with pressure support (i.e. CO2 and O2 levels could not be adequately corrected, a low or fluctuating tidal volume requires more precise monitoring and volume settings that cannot be accomplished with a bi-level device with back up feature)

the member has tried bi-level therapy and bi-level therapy with a backup feature and found to be ineffective or not tolerated.

II. Treatment of ONE of the following conditions of respiratory insufficiency (A-G):

A. Restrictive lung disease when the member meets the following:

1. Member has chronic respiratory failure defined by:

i. Nocturnal desaturation (SpO2) ≤ 88% for five continuous minutes while on the member’s usual FiO2, AND

ii. A diagnosis of obstructive sleep apnea has been excluded.

B. Chronic obstructive pulmonary disease (COPD) when the member meets the following:

1. Member has chronic respiratory failure symptoms defined by morning headaches, restless sleep, nightmares, enuresis, daytime hypersomnolence, AND

2. Any of the following physiologic criteria:

C. Progressive neuromuscular disorder such as but not limited to:

D. Chest wall deformity

E. Acute poliomyelitis

F. Spinal cord diseases/conditions OR

G. Central hypoventilation syndrome or obesity hypoventilation.

III. Member has had optimal medical therapy for underlying respiratory disorders AND

IV. Member is able to protect airway and clear secretions adequately AND

V. Member's reversible contributing factors have been treated (e.g., obstructive sleep apnea, hypothyroidism, congestive heart failure, severe electrolyte disturbance).

Indications for Invasive Positive Pressure Ventilation

Invasive ventilation meets the definition of medical necessity when:

1. The member meets criteria for non-invasive ventilation, and

2. The member has a condition or their condition progresses such that they have persistent symptomatic respiratory failure and no longer tolerate or can improve with a noninvasive interface.

Second Ventilators and Back up Ventilators

A second ventilator meets the definition of medical necessity if it is required to serve a different purpose than the primary ventilator, as determined by the member’s medical needs. (e.g. A member confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed. Without two pieces of equipment, the member may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.)

NOTE: A second ventilator must be distinguished from a back-up ventilator. A back-up ventilator is defined as an identical or similar device used to meet the same medical needs for the member but provided at the bedside as a precaution in case of malfunction of the primary ventilator. The member’s Durable Medical Equipment (DME) provider is responsible for ensuring that the member’s medical needs will be met on a continuous and ongoing basis.

Use of positive pressure ventilators for all other indications does not meet the definition of medical necessity including:

Treatment of obstructive sleep apnea, even though the ventilator equipment may have the capability of operating in a CPAP (E0601) or bi-level PAP (E0470) mode (clinical outcomes has not been shown to be superior to other standard treatments (e.g., CPAP, BiPAP));

Treatment of a condition with a non-invasive positive pressure ventilator that can be managed by an E0470/E0471 and would preclude the use of an E0466 when basic PAP could be equally efficacious

Clinical conditions that require bi-level functionality for intermittent and relatively short durations of respiratory support would not be appropriate for a positive pressure ventilator (E0466) even though the ventilator equipment may have the capability of operating in a bi-level PAP mode.

BILLING/CODING INFORMATION:

HCPCS Coding

E0465

Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

E0466

Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)

Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (CPAP and bi-level PAP) to traditional pressure and volume ventilator modes. This creates the possibility that one piece of equipment may be able to replace numerous and different pieces of equipment. Equipment with multifunction capability creates the possibility of errors in claims submitted for these items.General principles of correct coding require that products assigned to a specific HCPCS code only be billed using the assigned code. Thus, using the HCPCS codes for CPAP (E0601) or bi-level PAP (E0470/E0471) devices for a ventilator (E0466) used to provide CPAP or bi-level PAP therapy is incorrect coding. Claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as incorrect coding.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following were reviewed on the last guideline reviewed date and located at cms.gov:

The following was reviewed on the last guideline reviewed date: Correct Coding and Coverage of Ventilators-Revised May 2016, located at cgsmedicare.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

09-E0400, Oxygen
09-E0000-21, Positive Airway Pressure Devices

OTHER:

None applicable

REFERENCES:

  1. Agency for Healthcare Research and Quality Comparative Effectiveness Review Number 68, Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure, located at effectivehealthcare.ahrq.gov.
  2. Agency for Healthcare Research and Quality, Project Title: Noninvasive Positive-Pressure Ventilation (NPPV) for Acute Respiratory Failure, April 21, 2011; located at ahrq.gov.
  3. Centers for Medicare & Medicaid Services (CMS), Decision Memo for Noninvasive Positive Pressure RADs for COPD (CAG-00052N), accessed at cms.gov 03/21/17.
  4. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1), accessed at cms.gov 03/21/17.
  5. CGS Administrators, LLC, Correct Coding and Coverage of Ventilators-Revised May 2016, accessed at cgsmedicare.com 03/21/17.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the Florida Blue Medical Policy & Coverage Committee on 04/27/17.

GUIDELINE UPDATE INFORMATION:

05/15/16

New Medical Coverage Guideline.

12/15/16

Revision; description, position statement, and coding sections updated; formatting changes.

05/15/17

Annual review; guideline title, description, position statements, coding, and references updated.

Date Printed: June 24, 2017: 11:30 AM