CG-MED-79 Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

This policy addresses diaphragmatic/phrenic nerve stimulation and diaphragm pacing systems (e.g., FDA-approved NeuRx DPS) for ventilatory support. Coverage is medically necessary for adults (18+) as an alternative to invasive mechanical ventilation when all are met: ventilatory failure due to stable high spinal cord injury or central alveolar hypoventilation syndrome; inability to breathe spontaneously for ≥4 continuous hours without a ventilator; visible diaphragm movement with fluoroscopic stimulation; stimulation permits ≥4 hours/day of independent breathing; and the patient has normal chest anatomy, normal consciousness, and can complete required training/rehab. Not covered when the individual can breathe ≥4 hours without a ventilator, the insufficiency is temporary, or for other indications including significant cardiac, pulmonary, or chest wall disease that would still preclude >4 hours of spontaneous breathing even with the device.

"Diaphragmatic/Phrenic StimulationDiaphragmatic/phrenic nerve stimulation with an FDA-approved device is consideredmedically necessaryas an alternative to invasive mechanical ventilation for individ..."