BlueCross BlueShield of Tennessee Medical Policy Manual

Non-invasive Positive Pressure Ventilators (In-Home Use)

DESCRIPTION

A non-invasive positive pressure ventilator (NIPPV) provides ventilatory support through a non-invasive interface, such as a nasal mask, full-face mask or helmet. NIPPV is utilized in the acute care setting as short-term life support therapy for respiratory conditions that generally respond relatively quickly to therapy (e.g.  acute-on-chronic respiratory failure, COPD, post-op respiratory distress). Evidence-based data demonstrates that use of NIPPV in hospitalized individuals reduces mortality and morbidity associated with invasive (e.g. endotracheal or tracheotomy) mechanical ventilation (e.g. nosocomial infections, pneumonia, and length of hospital stay).  NIPPV during an acute exacerbation is often applied intermittently or continuously to reduce the (life-threatening) ventilatory failure while simultaneously administering medical therapeutics. Following optimal recovery the individuals is weaned and NIPPV treatment is terminated. NIPPV can also be useful in the weaning process from invasive mechanical ventilation.

Recently NIPPV has been explored for use in the homecare environment (e.g. Trilogy™, Newport™, VELA®, iVent, Puritan Bennett 540™, and LTV®). Home NIPPV may be employed in continuous daily use for ventilator dependent individuals (e.g. neuromuscular diseases). It is also being investigated as an intermittent treatment for other chronic respiratory diseases (e.g., chronic obstructive pulmonary disease, obesity hypoventilation syndrome, diffuse parenchymal lung disease) and nocturnal respiratory insufficiency.

This policy does not address other respiratory assist devices (e.g. CPAP, BiPAP)

POLICY  

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

Available data is insufficient to confirm improved outcomes of NIPPV in individuals with stable severe COPD. Further investigation is needed with larger populations to determine appropriate candidates for NIPPV and validate long-term outcomes. Studies are needed that can explore improved compliance; decreased adverse events associated with non-compliance, and validate health outcomes of home NIV.

SOURCES

Albert, R., Au, D., Blackford, A., Casaburi, R., Cooper, A., Criner, G., et al. (2016, October) A randomized trial of long-term oxygen for COPD with moderate desaturation (LOTT Study).  The New England Journal of Medicine, 135 (17), 1617-1627. (Level 3 evidence)

Ankjaergaard, K., Tonnesen, P., Laursen, L., Hansen, E., Andreassen, H., and Wilcke, J. (2016, February) Home Non Invasive Ventilation (NIV) treatment for COPD patients with a history of NIV-treated exacerbation; a randomized, controlled, multi-center study. BMC Pulmonary Medicine. 16:32. (Level 2 evidence)

British Thoracic Society. (2012). Guidelines for respiratory management of children with neuromuscular weakness. Retrieved July 26, 2013 from: http://www.britthoracic.org.uk.

Cahaba Government Services Administrators, LLC (2017, January) Local Coverage Determination: LCD Respiratory assist devices (L33800). Retrieved November 2113, 2017 from: https://www.cms.gov.

Cheng, S., Chan, V., & Chu, C. (2012). Compliance with home noninvasive ventilation. Respirology, 12 (17), 735-736. (Level 5 evidence)

Cheung, A., Chan, V., & Chu, C. (2010). Home noninvasive ventilation in COPD. Breathe, 2010 (6), 260-266. (Level 1 evidence - Independent)

Coughlin, S., Liang, W., and Parthasarathy, S. (2015, November) Retrospective Assessment of Home Ventilation to Reduce Rehospitalization in Chronic Obstructive Pulmonary Disease. Journal of Clinical Sleep Medicine. (6):663-670. (Level 4 evidence)

Duiverman, M., Wempe, J., Bladder, G., Vonk, J., Zilstra, J., Kerstjens, H., et al. (2011). Two-year home-based nocturnal noninvasive ventilation added to rehabilitation in chronic obstructive pulmonary disease patients: a randomized controlled trial. Respiratory Research, 12 (1), 112. (Level 2 evidence)  

Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Retrieved November 13, 2017 from http://www.guideline.gov.

Liu, Y., Dai, B., Su, J., Peng, Y., Tan, W., and Zhao, H. (2017, May) Effect of home noninvasive positive pressure ventilation on patients with severe stable chronic obstructive pulmonary disease: a meta-analysis. Zhonghua Jie He, 40 (5), 354-362. Abstract retrieved November 13, 2017 from PubMed database.

National Institute for Health and Care Excellence (2010, June) Clinical guideline: chronic obstructive pulmonary disease in over 16s: diagnosis and management. Retrieved November 13, 2017 from: www.nice.org.uk. 

National Institute for Health and Care Excellence (2016, February) Clinical guideline: motor neutone disease: assessment and management. Retrieved November 13, 2017 from: www.nice.org.uk.

Salturk, C., Karakurt, Z., Takir, H., Balci, M., Kargin, F. Mocin, O., et. al. (2015, November) Comparison of exercise capacity in COPD and other etiologies of chronic respiratory failure requiring non-invasive mechanical ventilation at home: retrospective analysis of 1-year follow-up. International Journal of COPD. 2015:10 2559–2569. (Level 2 evidence)

Tissot, A., Jaffre, S. Gagnadoux, F., Levaillant, M., Corne, F., Chollet, S., et. al., (2015, October) Home non-invasive ventilation fails to improve quality of life in the elderly: results from a multicenter cohort study. PLOS One. DOI:10.1371. (Level 3 evidence)

Titlestad, I., Lasse, A., Vestbo, J. (2013). Long term survival for COPD patients receiving non-invasive ventilation for acute respiratory failure. International Journal of COPD, 13 (8), 215-219 (Level 4 evidence)

U. S. Food and Drug Administration. (2006, January). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K053270. (iVent™) Retrieved June 25, 2013 from:  http://www.accessdata.fda.gov.  

U. S. Food and Drug Administration. (2008, December). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K08724. (Newport HT500®) Retrieved June 25, 2013 from:  http://www.accessdata.fda.gov.

U. S. Food and Drug Administration. (2009, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083526. (Trilogy) Retrieved June 25, 2013 from http://www.accessdata.fda.gov.

Windisch, W., Haenel, M., Storre, J., & Dreher, M. (2009). High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD. International Journal of Medicine, 6 (2), 72-76. (Level 4 evidence)

Winifred S. Hayes, Inc. Medical Technology Directory (2017, July) Search & Summary: Noninvasive positive pressure ventilation using the Trilogy100 (Respironics Inc.) for intermittent home use in adults with severe chronic obstructive pulmonary disease. Retrieved November 13, 2017 from www.hayesinc.com.

ORIGINAL EFFECTIVE DATE:  12/14/2013

MOST RECENT REVIEW DATE:  12/20/2017 

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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