Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID-19 infection and Hypersensitivity pneumonitis
Treatment: Ventilator (L2K device)
The insurer denied: Ventilator (L2K device)
The denial is overturned.

The patient is an adult female who has a history of hypersensitivity pneumonitis (HP). According to clinic notes from her physician, the patient has a history of HP (hypersensitivity pneumonitis) and suffered an episode of COVID-19 infection, which negatively impacted her breathing despite treatment with Paxlovid. She was reported to have indicated that if she had not had the non-invasive ventilator (NIV) L2K (Life2000), she would have required hospitalization and possibly mechanical ventilation. The patient was being treated with a combination of CellCept, Ofev and prednisone at 20 milligrams/day. She was also using albuterol, montelukast and Anoro Ellipta. At that point she was reporting a non-productive cough that was difficult to control. She was having dyspnea on exertion that required 2 Liters/minute of supplemental oxygen via nasal cannula. At that time, the patient's physician noted that the patient was able to ambulate 550 feet on 2 Liters/minute. At that point, she had to stop due to profound dyspnea (Borg = 8) with a respiratory rate of 38/minute and HR (heart rate) of 141/minute. Her oxygen saturation on 2 Liters/minute was in the low to mid 90s. Her spirometry that day was unchanged from a prior study and showed an absolute FEV1 (forced expiratory volume 1 second) of 1.64 Liters with FEV1 (forced expiratory volume 1 second)/FVC (forced vital capacity) of 85% (percent). Spirometry showed FVC (forced vital capacity) of 2.01 Liters (50% predicted), FEV1 (forced expiratory volume 1 second) of 1.68 Liters (51% predicted) and FEV1 (forced expiratory volume 1 second)/FVC
(forced vital capacity) of 82%. Her prior spirometry showed FVC (forced vital capacity) of 1.69 Liters (41% predicted), FEV1 (forced expiratory volume 1 second) of 1.28 Liters (39% predicted) and FEV1 (forced expiratory volume 1 second)/FVC
(forced vital capacity) of 76%. CT (computed tomography) of the chest showed interstitial prominence most notable along the posterior aspects of the lower to mid lung fields. Cylindrical bronchiectasis, slightly improved, and subpleural blebs in the
upper lung fields were also present. At this point, the provider felt that her dyspnea was related to work of breathing rather than hypoxemia and recommended a portable NIV and/or tidal volume assisted ventilation (TAV) device. She was introduced to the Hill-Rom L2K (Life 2000 Ventilation System) and Inogen TAV (tidal assist ventilator) units. She was trialed on both, and was able to ambulate to 600 feet never exceeding Borg =(equal) 3 and RR (respiration rate) = 24/minute with oxygen saturation in the mid to high 90s on the Hill-Rom L2K (Life2000). The patient found this to be 10/10 in terms of effect on her dyspnea, which was superior to her experience with the Inogen TAV (tidal assist ventilator).

At issue is the Hill-Rom L2K (Life2000), a portable non-invasive ventilator. The health plan's denial of coverage cited that what was necessary for approval were failure of CPAP (continuous positive airway pressure) and BiPAP (bi-level positive airway pressure) for nocturnal use.

The requested ventilator is medically necessary.
The patient has an appropriate medical condition and disability. She showed significant improvement with use of the device even prior to her episode of COVID infection.