Sleep & respiratory: Stay informed & advocate

Q. What are some of the proposed changes to the NCD for NIPPV in COPD patients? 

A. At the time of writing, CMS is in the comment period for the proposed NCD on non-invasive positive pressure ventilation (NIPPV) for patients with chronic respiratory failure due to COPD. The final policy is expected in June. While CMS is to be commended for removing outdated requirements, the proposed policy introduces logistical challenges for HME providers. 

To qualify for a bilevel device with a backup rate, patients must meet “high intensity” therapy criteria: an IPAP > 20 cm H₂O and a respiratory rate > 14 breaths per minute. However, the American Thoracic Society states that the “certainty of evidence is low or very low for all outcomes,” with no head-to-head trials, leading to only a “conditional” recommendation. 

The proposed requirement of five hours of nightly use is problematic. Studies estimate that COPD patients average only 3.4–6.7 hours of sleep per night. Many with COPD struggle with insomnia and disrupted sleep, making rigid adherence thresholds unrealistic. Furthermore, the percentage of nights the five-hour threshold must be met is not defined.  

The NCD also adds a 180-day reevaluation requirement to maintain coverage, with at least one measurable outcome showing improvement. The list of possible measures from which to choose includes repeat testing of ABG—an invasive and logistically difficult process, especially in rural or outpatient settings.  

Operational concerns for HMEs include a mandate that patients use the same type of device 24 hours before discharge, which could delay discharge and increase costs. The reevaluation process will likely raise administrative burdens and may result in more frequent device retrievals and restarts. 

HME providers can play a critical role in shaping final policy. By staying informed, submitting comments to CMS, and advocating for practical, evidence-based implementation strategies, providers can help reduce barriers to care and support better outcomes for patients with COPD. 

Colleen Lance, MD, is chief medical officer at React Health. Reach her at Colleen.Lance@ReactHealth.com.