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Definition Clarification for Back-Up and Replacement Ventilators for Respiratory Equipment and Supplies

Last updated on 3/6/2020

Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after April 1, 2020, clarification language will be added to the Respiratory Equipment and Supplies – Home Health Texas Medicaid medical policy to distinguish the difference between back-up and replacement ventilators.

Back-up Mechanical Ventilator

A back-up ventilator is defined as an identical or similar device used to meet the same medical needs as the primary ventilator for the client, but provided in the home as a precaution in case of malfunction of the primary ventilator. Requests for a back-up ventilator in the home must meet both of the following criteria to be considered medically necessary:

  • The patient cannot maintain spontaneous ventilations for four or more consecutive hours.
  • The patient lives in an area where a replacement ventilator cannot be provided within two hours.

Prior authorization requests for a back-up ventilator must include all of the following documentation:

  • The amount of time the patient is able to maintain spontaneous ventilation.
  • The distance and/or delivery time of a replacement ventilator to the patient’s home.

All requests for a back-up ventilator in the home must be sent to the TMHP Medical Director for review.

Replacement Ventilator

A replacement is defined as a replacement for the primary ventilator due to mechanical or other malfunction; it is considered a part of the rental agreement; and it is not authorized separately from the primary ventilator request.

For more information, call the TMHP Contact Center at 800-925-9126.