Optimal NIV Medicare Access Promotion: Patients With Hypoventilation Syndromes

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 PCO 2 and venous blood gases in lieu of arterial blood gases; (2) not requiring PCO 2 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.

Practical Guide to Management of Long-Term Noninvasive Ventilation for Adults With Chronic Neuromuscular Disease

“…98 In 2021, the Optimal NIV Medicare Access Promotion (ONMAP) technical expert panel representing the American Thoracic Society, the American College of Chest Physicians, the American Association of Respiratory Care, and the American Academy of Sleep Medicine published consensus recommendations for updating CMS coverage criteria for noninvasive positive pressure ventilation devices. 99,100 Noteworthy among the recommendations are increasing the qualifying vital capacity threshold to <80% predicted if accompanied by respiratory symptoms, and acceptance of an end-tidal or transcutaneous PCO2 as a substitute for arterial puncture to document hypercapnia. Recommendations of the expert panel for thoracic restrictive diseases are detailed in Table 4.…”

International Survey of the Tools Used for Assessment, Monitoring and Management of Home Mechanical Ventilation Patients

“…Furthermore, in line with previous EUROVENT data [1], other chronic lung diseases are treated with HMV. Despite guidelines [3,5] stating that carbon dioxide measurements (arterial blood gas or transcutaneous) are mandated in order to make a diagnosis of nocturnal hypoventilation-with recent data highlighting a targeted reduction in daytime and nocturnal carbon dioxide levels improving the patients' clinical outcome [6,7,[16][17][18][19][20]-the current survey showed that when initiating HMV and prior to discharge post initiation, the SpO 2 monitoring and physiological and ventilator downloaded data were employed more frequently than carbon dioxide measurements. Surprisingly, some respondents reported that they never use carbon dioxide measurements to titrate HMV.…”

OSA and Chronic Respiratory Disease: Mechanisms and Epidemiology

“…Diagnosis of hypoventilation is often delayed or missed [120], and patients experience increased healthcare utilization leading up to diagnosis than matched controls [121]. Observational data primarily focusing on obesity hypoventilation suggest that patients with hypoventilation syndromes in the hospital should be empirically started on PAP therapy to reduce mortality (4.9% vs. 22.7% at six months) and risk of readmission [122][123][124].…”