Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a new three-month trial for a continuous positive airway pressure 
(CPAP) device. 
 
You asked the Plan to pre-approve the CPAP device trial. You say that this device was sent for repairs in 
October and by December still had not been returned when the denial was issued. You do not believe that this 
has been reviewed correctly as the enrollee has used the CPAP regularly for 20 years. The Plan denied your 
request. The Plan says that the compliance report does not show that the CPAP was used for at least 4 hours on 
the required percentage of nights to allow for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The file submitted by the Plan does not include sufficient information about the 
current situation. Per the appeal documentation, the enrollee had been using a CPAP device which was sent for 
repair in October 2021. No information was given as to whether the Plan had approved or covered the CPAP 
prior to this date. The record shows that prior authorization was requested for the CPAP on December 14, 
2021, which was denied on December 24, 2021. This denial cites that continuation of CPAP therapy beyond 
the first three months is only covered when the device is used for at least 4 hours on 70% of nights. However, it 
is not clear that the enrollee was in the first three months of using the device during the time period for which 
compliance data was shown. In addition, the time period shown in the data is not the entire three months, and 
the criteria indicate that the 70% adherence must be reached during any 30-day period during the first three 
months of using the CPAP device. This compliance data is also not considered valid because the 30-day period 
referenced is immediately prior to when the device was reportedly returned for repairs. Without more 
documentation, it is not known whether the adherence was affected by a malfunction for which the reported 
repairs were required. 
 
Maximus has not requested clarification from the Plan as the Plan already delayed a decision by an additional 
month due to missing the appeal time frame. We find it is not in the enrollee's best interest to extend the time 
frame further to obtain these documents. Given the issues presented, we find that it is reasonable to approve a 
three-month trial with the CPAP device, during which time the enrollee will be required to meet the adherence 
criteria of use for more than 4 hours on 70% of nights in order to approve coverage beyond three months. We 
find that the denial of coverage from the Plan is not substantiated based on the available information. Therefore, we decided that the Plan has to pre-approve a new three-month trial for a continuous positive airway 
pressure (CPAP) device.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.