Optimal NIV Medicare Access Promotion: Patients With Hypoventilation Syndromes: 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 existing coverage criteria for home noninvasive ventilation (NIV) do not recognize the diversity of hypoventilation syndromes and advances in technologies. This document summarizes the work of the hypoventilation syndromes Technical Expert Panel working group. The most pressing current coverage barriers identified were: (1) overreliance on arterial blood gases (particularly during sleep); (2) need to perform testing on prescribed oxygen; (3) requiring a sleep study to rule out OSA as the cause of sustained hypoxemia; (4) need for spirometry; (5) need to show bilevel positive airway pressure (BPAP) without a backup rate failure to qualify for BPAP spontaneous/timed; and (6) qualifying hospitalized patients for home NIV therapy at the time of discharge. Critical evidence support for changes to current policies includes randomized controlled trial evidence and clinical practice guidelines. To decrease morbidity and mortality by achieving timely access to NIV for patients with hypoventilation, particularly those with obesity hypoventilation syndrome, we make the following key suggestions: (1) given the significant technological advances, we advise acceptance of surrogate noninvasive end-tidal and transcutaneous Pco₂ and venous blood gases in lieu of arterial blood gases; (2) not requiring Pco₂ measures while on prescribed oxygen; (3) not requiring a sleep study to avoid delays in care in patients being discharged from the hospital; (4) remove spirometry as a requirement; and (5) not requiring BPAP without a backup rate failure to approve BPAP spontaneous/timed. The overarching goal of the Technical Expert Panel is to establish pathways that improve clinicians' management capability to provide Medicare beneficiaries access to appropriate home NIV therapy. Adoption of these proposed suggestions would result in the right device, for the right type of patient with hypoventilation syndromes, at the right time.

Keywords: Bilevel PAP; CPAP; home mechanical ventilator; noninvasive ventilation; obesity hypoventilation; volume assured pressure support.

Figure 1

Definition of clinical conditions related to hypoventilation. NMD = neuromuscular disease.

Figure 2

Suggestions for outpatient NIV support for hypoventilation syndromes. AE = auto-EPAP; BPAP = bilevel positive airway pressure; HMV = home mechanical ventilation; NIV = noninvasive ventilation; NMD = neuromuscular disease; SDB = sleep-disordered breathing; S = spontaneous; S/T = spontaneous/timed; VAPS = volume-assured pressure support.