Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve a home ventilator. We also decided that the Plan does not have to
pre-approve an oxygen concentrator and portable oxygen system.
You asked the Plan to pre-approve a home ventilator, oxygen concentrator and portable oxygen system. You
say that these items/services are medically necessary. The Plan says that the enrollee does not meet Medicare
criteria for coverage of these items/services.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD. The rules also say that to qualify for portable oxygen, the patient must meet the criteria
for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from
the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen
solely based on blood gas studies obtained during sleep.
To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a home ventilator, oxygen concentrator
and portable oxygen system. Our reviewer says that a home ventilator is reasonable and medically
necessary. Home supplemental oxygen is not medically necessary. Our physician reviewer found that the
enrollee is ventilator dependent. Removal of the ventilator would be life threatening.
Medicare covers a home ventilator for the enrollee's diagnosis. The medical records do not include evidence of
hypoxemia when being ventilated on room air, while medically stable. Medicare criteria for oxygen
supplementation are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a home ventilator have been met, but criteria for an oxygen concentrator and
portable oxygen system have not been met. Therefore, we decided that the Plan has to pre-approve a home
ventilator but does not have to pre-approve an oxygen concentrator and portable oxygen system.
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.