Current Medicare policy covers ventilators, both positive and negative pressure types, for the treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. With changes in technologies over the past decade, the clinical relationship between home mechanical ventilators and bi-level devices (identified as respiratory assist devices by CMS) has become strongly interrelated. As a result local coverage policies are out-of-date and do not reflect current standards of practice. AARC and other pulmonary organizations submitted a proposal to CMS to develop a national coverage determination with recommendations that will improve quality of care for respiratory patients and lower costs. Issues involve recognizing the need to develop specific categories of mechanically ventilated patients, using proper terminology recognized by the Food and Drug Administration, merging the current local coverage determination for “respiratory assist devices” into a revised national coverage decision for home mechanical ventilation and eliminating current policies that are not supported by scientific evidence. Unfortunately, CMS has chosen not to proceed with the request. The most likely next step will be to pursue a legislative amendment.