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 or face mask. 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 (e.g. nosocomial infections, pneumonia, and length of hospital stay) associated with invasive mechanical ventilation.  NIPPV during an acute exacerbation is often applied intermittently or continuously to reduce ventilatory failure while simultaneously administering medical therapeutics. Following optimal recovery the individuals is weaned and NIPPV treatment is terminated. NIPPV may 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®). Similar to BiPAP, NIPPV can provide both volume and pressure ventilation, but can be more finely tuned to meet the individual’s needs. Home NIPPV may be employed in continuous daily use for ventilator dependent individuals (e.g. neuromuscular diseases, thoracic cage abnormalities, severe chronic obstructive pulmonary disease, and obesity hypoventilation syndrome). NIPPVs are portable with an internal battery that lasts up to six hours.

This policy does not address other respiratory assist devices; for example CPAP and BiPAP have an MCG: CPAP ACG: A-0431, BPAP ACG: A-0994).

POLICY  

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

The clinical outcomes when using positive pressure ventilation for Obstructive Sleep Apnea (OSA) have not been shown to be superior to other approaches (e.g., CPAP, BiPAP).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 for diagnosis other than those stated in the above policy.

SOURCES

Ankjaergaard, K., Tonnesen, P., Laursen, L., Hansen, E., Andreassen, H., & Wilcke, J. (2016). 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.

Castillejo, O., de Lucas R., López,  M., Resano, B., Rodríguez, P., Caicedo, M., et al. (2015). Noninvasive mechanical ventilation in patients with obesity hypoventilation syndrome. Long-term outcome and prognostic factors. Archivos de Bronconeumología, 51 (2), 61-8. Abstract retrieved May 29, 2018 from PubMed database.

CGS Administrators, LLC. (2017, January). Local Coverage Determination: LCD Respiratory assist devices (L33800). Retrieved November 21, 2017 from https://www.cms.gov.

Howard, M., Piper, A., Stevens, B., Holland, A., Yee, B., Dabscheck, E., et al. (2017). A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome. Thorax, 72 (5), 437-444. Abstract retrieved May 29, 2018 from PubMed database.

Köhnlein, T., Windisch, W., Köhler, D., Drabik, A., Geiseler, J., Hartl, S., et al. (2014). Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Lancet Respiratory Medicine, 2 (9), 698-705. Abstract retrieved July 16, 2018 from PubMed database.

Liu, Y., Dai, B., Su, J., Peng, Y., Tan, W., & Zhao, H. (2017). 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.

Murphy, P., Rehal, S., Arbane, G., Bourke, S., Calverley, P., Crook, A., et al. (2017). Effect of home noninvasive ventilation with oxygen therapy vs oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation: a randomized clinical trial. JAMA, 317 (21), 2177-2186. Abstract retrieved July 16, 2018 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.

Osadnik, C., Tee, V., Carson-Chahhoud, K., Picot, J., Wedzicha, J., & Smith. B. (2017). Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Systems Review, CD004104. Abstract retrieved May 29, 2018 from PubMed database.

Tissot, A., Jaffre, S. Gagnadoux, F., Levaillant, M., Corne, F., Chollet, S., et al. (2015). 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)

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 fromhttp://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.

ORIGINAL EFFECTIVE DATE:  12/14/2013

MOST RECENT REVIEW DATE:  7/11/2019 

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.

This document has been classified as public information.