CG-DME-47 Noninvasive Home Ventilator Therapy for Respiratory Failure

This policy addresses noninvasive positive pressure ventilation (NPPV) with a home ventilator for respiratory failure. Coverage is medically necessary when respiratory failure is primarily due to neuromuscular disease (e.g., ALS) or restrictive thoracic disease (e.g., thoracic cage abnormalities) with either PaCO2 ≥45 mm Hg while awake on the individual’s usual FiO2 or maximum inspiratory pressure ≤60 cm H2O, or for hypercapnic end-stage COPD when policy criteria are met. Home NPPV is not medically necessary when these criteria are not met and for other conditions such as chronic stable COPD without hypercapnia and central sleep apnea of heart failure.

"Noninvasive positive pressure ventilation therapy (NPPV) with a home ventilatoris consideredmedically necessaryfor the following conditions (A, B,orC):"

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