CG-DME-26 Back-Up Ventilators in the Home Setting Form

This document addresses the medically necessary indications for the use of back-up (or second additional) ventilators in the home setting, for use as a “back-up” machine, if needed.

Mechanical ventilation may be defined as a life support system designed to replace or support normal ventilatory lung function (AARC 2007).

Clinical Indications

Medically Necessary:

The use of a back-up (second) ventilator in the home setting is considered medically necessary when all of the following criteria are met:

1. The individual cannot maintain spontaneous ventilations for 4 or more consecutive hours; and
2. The individual lives in an area where a replacement ventilator cannot be provided within 2 hours.

The use of a back-up (second) ventilator in the home setting is considered medically necessary for the following additional indication, when applicable:

1. For individuals who require mechanical ventilation during mobility, as prescribed in their plan of care.

Not Medically Necessary:

The use of a back-up (second) ventilator in the home setting is considered not medically necessary when the above criteria are not met.