For patients with chronic obstructive pulmonary disease (COPD) without significant hypercapnia (PaCO2 < 52 mmHg) and with obstructive sleep apnea, see policy 2.01.18 (Diagnosis of Obstructive Sleep Apnea Syndrome) and 8.01.64 (Medical Management of Obstructive Sleep Apnea Syndrome). Nocturnal bilevel positive airway pressure (BPAP) with backup rate may be considered medically necessary for individuals with COPD and chronic respiratory failure (see Policy Guidelines) who meet either of the following: Chronic stable daytime (awake) hypercapnia (PaCO2>52 mmHg) OR
Daytime (awake) hypercapnia (PaCO2>52 mmHg) at least 2 weeks after discharge from the hospital for an acute exacerbation with decompensated respiratory acidosis.
Non-invasive home mechanical ventilation may be considered medically necessary for individuals with COPD who meet the following criteria:
Qualify for a BPAP device AND meet at least one of the following:
Higher pressure is needed to reduce hypercapnia than can be achieved with a bilevel device during titration (typically >25cm H2O); OR
Severe hypoxemia requiring fraction of inspired oxygen (FIO2) >40% or >5 L/min; OR
Daytime use (battery operated unit) is required to reduce hypercapnia.
Individuals with COPD who are started on BPAP at discharge from hospitalization may continue for up to 3 months to provide time to stabilize and complete reevaluation.
Non-invasive positive airway pressure for COPD is considered investigational under all other conditions.
Bilevel positive airway pressure may be considered medically necessary for individuals with thoracic restrictive disorders due to neuromuscular disease who meet any of the following:
Pulmonary function tests:
Spirometry (upright or supine) with vital capacity <50% predicted or <80% predicted with associated symptoms (orthopnea, dyspnea, morning headaches, excessive daytime sleepiness, or unrefreshing sleep); OR Maximal inspiratory pressure <60 cm H2O or maximum expiratory pressure (MEP) <40 cm H2O; OR Peak cough flow (PCF) <270 L/min for age ≥12 years or PCF <5th percentile for age <12 years; OR Sniff nasal inspiratory pressure (SNIP) <70 cm H2O in males, SNIP <60 cmH2O in females for age ≥12 years. Hypercapnia Chronic stable daytime (awake) hypercapnia with PaCO2 ≥45 mmHg (capillary blood gas can be used in children); OR Venous blood gas PCO2, end-tidal PCO2, or transcutaneous PCO2, ≥50 mmHg; OR Hypoxia Overnight oximetry in-laboratory or home sleep test with saturation <88% for 5 minutes; Overnight oximetry: SpO2 ≤ 90% for ≥ 2% of sleep time. Non-invasive home mechanical ventilation may be considered medically necessary for individuals with thoracic restrictive disorders due to neuromuscular disease who meet the following: Qualify for a BPAP device; AND BPAP fails; OR Have extreme loss in function with vital capacity <30%; OR Non-invasive ventilation is needed for >10 hours per day; OR
Severe breathlessness (e.g., with speaking at rest); OR
Worsening daytime hypercapnia with need for mouthpiece ventilation; OR
Daytime use (battery operated unit) is required to reduce hypercapnia or dyspnea.
Bilevel positive airway pressure may be considered medically necessary for individuals with hypoventilation syndromes who meet the following criteria:
Awake or sleep hypoventilation with hypercapnia (one of the following is met):
Awake hypoventilation with chronic stable daytime (awake) hypercapnia (PaCO2 ≥ 45 mmHg); OR
Venous blood gas PCO2, end-tidal PCO2, or transcutaneous PCO2 ≥50 mmHg; OR
Sleep hypoventilation with hypercapnia:
≥10 mmHg increase from baseline awake PCO2 and to a value > 50 mmHg for ≥10 min; OR
PCO2 ≥55 mmHg for ≥10 min; AND
Low clinical suspicion for COPD or neuromuscular disease; AND
One of the following conditions are met:
Obesity with body mass index (BMI) ≥30 kg/m2; OR
Decreased respiratory drive due to opioid or substance use; OR
Advanced lung disease other than COPD (e.g., end-stage or advanced interstitial lung disease); AND
Individual was discharged from inpatient stay with persistent awake hypoventilation (hypercapnia) on BPAP.
A reassessment with a provider within 3 months (30 to 90 days) is required and an attended polysomnogram (PSG) should be performed to assess appropriateness of positive airway pressure modality (home sleep apnea test is acceptable if attended PSG is not obtainable); OR
Individual is ambulatory and sleep study indicates that BPAP is necessary for sleep-disordered breathing, or individual with severe obstructive sleep apnea is continuous positive airway pressure intolerant or continuous positive airway pressure was proven ineffective.
Non-invasive home mechanical ventilation may be considered medically necessary for individuals with hypoventilation syndromes who meet the following:
Qualify for a BPAP device and at least one of the following:
Higher pressure is needed to reduce hypercapnia than can be achieved with a bilevel continuous positive airway pressure device during titration (typically >25 cm H2O); OR
Severe hypoxemia requiring FIO2 >40% or >5 L/min; OR
Daytime use (battery operated unit) is required to reduce hypercapnia; OR
Tried and failed BPAP device with persistent hypercapnia despite 3 months of adequate adherence to prescribed positive airway pressure therapy with:
Awake PaCO2 ≥45 mmHg; OR
Awake venous blood gas PCO2, end-tidal PCO2, or transcutaneous PCO2 ≥50 mmHg.
