Executive Summary: Optimal NIV Medicare Access Promotion: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society

Abstract

The current national coverage determinations (NCDs) for noninvasive ventilation for patients with thoracic restrictive disorders, COPD, and hypoventilation syndromes were formulated in 1998. New original research, updated formal practice guidelines, and current consensus expert opinion have accrued that are in conflict with the existing NCDs. Some inconsistencies in the NCDs have been noted, and the diagnostic and therapeutic technology has also advanced in the last quarter century. Thus, these and related NCDs relevant to bilevel positive airway pressure for the treatment of OSA and central sleep apnea need to be updated to ensure the optimal health of patients with these disorders. To that end, the American College of Chest Physicians organized a multisociety (American Thoracic Society, American Academy of Sleep Medicine, and American Association for Respiratory Care) effort to engage experts in the field to: (1) identify current barriers to optimal care; (2) highlight compelling scientific evidence that would justify changes from current policies incorporating best evidence and practice; and (3) propose suggestions that would form the basis for a revised NCD in each of these 5 areas (thoracic restrictive disorders, COPD, hypoventilation syndromes, OSA, and central sleep apnea). The expert panel met during a 2-day virtual summit in October 2020 and subsequently crafted written documents designed to achieve provision of "the right device to the right patient at the right time." These documents have been endorsed by the participating societies following peer review and publication in CHEST and will be used to inform efforts to revise the current NCDs.

Keywords: Medicare; access; noninvasive; optimal; ventilation.

Figure 1

Criteria sufficient to initiate BPAP device in TRDs. ABG = arterial blood gas; BPAP = bilevel positive airway pressure; HST = home sleep test; MIP = maximal inspiratory pressure; PSG = polysomnogram; SNIP = sniff nasal inspiratory pressure; TRD = thoracic restrictive disorders; VBG = venous blood gas; VC = vital capacity.

Figure 2

Suggested initiation and monitoring of noninvasive ventilation therapy in thoracic restrictive disorders. ABG = arterial blood gas; BPAP = bilevel positive airway pressure; Etco_{2 =} end-tidal measurement of PCO₂; HMV = home mechanical ventilator; MIP = maximal inspiratory pressure; O₂ = oxygen; Tcco₂ = transcutaneous measurement of PCO₂; VBG = venous blood gas; VC = vital capacity.

Figure 3

Suggested management of patients with COPD who require noninvasive ventilation. ABG = arterial blood gas; BPAP = bilevel positive airway pressure; HMV = home mechanical ventilator.

Figure 4

Advised evaluation and treatment pathway for CSA. CSA = central sleep apnea; O₂ = oxygen; PAP = positive airway pressure.

Figure 5

Suggestions for the definition of clinical conditions related to hypoventilation syndromes. NMD = neuromuscular disease.

Figure 6

Suggested management pathway of patients with hypoventilation. BPAP = bilevel positive airway pressure; CMS = Centers for Medicare & Medicaid Services; HMV = home mechanical ventilator; NMD = neuromuscular disease; PAP = positive airway pressure; S = spontaneous; SDB = sleep-disordered breathing; S/T = spontaneous/timed; VAPS = volume-assured pressure support.

Figure 7

Proposed treatment with CPAP and BPAP for patients with OSA. AHI = apnea-hypopnea index; BPAP = bilevel positive airway pressure; PAP = positive airway pressure; RDI = respiratory disturbance index.