Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ventilator dependent respiratory failure

Treatment: Durable medical equipment (DME) backup-ventilator (codes E1399 and E0465)

The insurer denied coverage for durable medical equipment (DME) backup-ventilator (codes E1399 and E0465).

The denial is overturned. 

This is a female patient with Nemaline Rod Myopathy. The patient has chronic respiratory failure and hypoxemia secondary to her neuromuscular condition. The patient is status post tracheostomy and percutaneous endoscopic gastrostomy (PEG).  The patient is on a ventilator 20 hours per day. The patient has underlying asthma and gastroesophageal reflux disease (GERD) in addition to restrictive lung disease from scoliosis in addition to her underlying neuromuscular condition.

This patient lives in a 3 level home and is mobile within her home via wheel chair.  The patient's ventilator settings are synchronized intermitted mandatory ventilation (SIMV) pressure-controlled (PC) 18, pressure-support (PS) 16, positive end-expiratory pressure (PEEP) 6, rate 14, and fraction of inspired oxygen (FiO2) 21 %. The patient's respiratory rate (RR) is adjusted depending on her rate of activity and needs for increased ventilation which can be detected easily by a capnograph. The patient's home medications include Xopenex, Dulera, and Pulmozyme. The patient is receiving daily physical therapy (PT) and her physician has ordered another additional ventilator to facilitate mobility and participation in daily PT which happens on another floor. The patient's first ventilator is at her bedside. In addition, the patient's physician has ordered a capnograph to monitor the patient's end-tidal carbon dioxide (EtCO2) which will give a non-invasive measurement of her ventilatory status.

This patient is ventilator dependent and suffers from a chronic neuromuscular condition which has resulted in chronic respiratory failure. The patient requires ventilatory support to stay alive. In addition, the patient needs daily PT to keep her muscles from atrophying and maintaining respiratory and general health. An additional ventilator is appropriate under these circumstances to improve the patient's mobility and participation in PT which happens on another floor. A capnograph is also essential for monitoring a patient's ventilatory status to see if the patient's ventilatory parameters need to be adjusted if increases in carbon dioxide (CO2) are noted. A pulse oximeter gives only a reading of oxygen (O2) saturations which can detect hypoxia but not hypercapnia and hypercapnic respiratory failure (which is what happens in patients with neuromuscular diseases).

Given the above, it is appropriate to approve an additional ventilator and capnograph.  Since this patient has ventilator dependent respiratory failure and needs the ventilator to keep alive a backup ventilator is appropriate to put the patient on it in case of malfunction of the primary ventilator. Thus, the durable medical equipment (DME) backup-ventilator is considered medically necessary for the patient. 

The carrier's denial of coverage for durable medical equipment (DME) backup-ventilator (codes E1399 and E0465) should be overturned. The medical necessity is substantiated.