MACs remove 'imminent death' requirement for vents

WASHINGTON - Recent guidance from the DME MACs on coverage criteria for ventilators is a move in the right direction, say industry stakeholders.

Specifically, the guidance removes the so-called “imminent death requirement,” which stated that patients must need a ventilator 24/7 for coverage.It's a requirement the MACs issued in April 2015 in an attempt to define criteria for vents vs. bi-level devices.

The new guidance doesn't go that far, but “makes very clear that any device which would be considered a ventilator that is used either in RAD mode or CPAP mode would be inappropriate,” said Kim Brummett, vice president of regulatory affairs for AAHomecare.

Several respiratory groups would like to see CMS go further and reconsider the National Coverage Determination for home ventilators, including bi-level devices.The American Association of Respiratory Care, the American College of Chest Physicians and the National Association for Medical Direction of Respiratory Care in April asked CMS to establish specific definitions for chronic respiratory failure, as well as for mechanical ventilators/ventilation, and to create objective, consistent criteria for providing the products.

Having greater clarity on what Medicare believes is the appropriate device would solve a lot of problems, say stakeholders.

“When the coverage criteria is not clear it's very difficult for providers to make a judgment call on if they are going to get paid or not,” said Chris Salmen, senior manager of market access for ResMed and a member of AAHomecare's ventilator work group. “When the clinicians are saying it's the right device but Medicare is saying it's not the right device, they get stuck in the middle and so do the patients.”

CMS has until the end of May to respond to the groups' request. Revising an NCD isn't something that happens often, says stakeholders

“CMS is reviewing the reconsideration request,” said Andrea Stark, a reimbursement consultant with MiraVista. “I think CMS recognizes that there are still some gray areas.”