Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve an extension of BiPAP approval for three months to allow more time to achieve tolerance and compliance. We decided that the Plan does not have to pre-approve continued BiPAP use after the three months if compliance criteria are not met.
You asked the Plan to pre-approve continued BiPAP and humidifier use. You say that you experienced prolonged difficulty in using the equipment. The Plan says that the requested services are not medically necessary.
We decided that the Plan has to pre-approve an extension of BiPAP approval for three months to allow more time to achieve tolerance and compliance.
The Plan follows Medicare rules. Medicare rules say that continued use of BiPAP is covered for certain indications. 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 continued BiPAP and humidifier use. Our reviewer says that the documentation supports that the BiPAP approval should be extended for three months to allow more time to achieve tolerance and compliance. Our physician reviewer found you have severe obstructive sleep apnea (OSA) but have been struggling with mask fit, leak, and tolerance. You also changed
sleep specialists recently. The records document significant efforts on your part to try to achieve mask fit and tolerance since the diagnosis of OSA in May of this year. The clinical note from September 1, 2021 indicates a new interface being tried. BiPAP approval should be extended for three months to allow more time to achieve tolerance and compliance. If compliance criteria are not met (at least 70% of days with at least four hours/day) at that point, the device will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an extension of BiPAP approval have been met. Therefore, we decided that the Plan has to pre-approve an extension of BiPAP approval for three months to allow more time to achieve tolerance and compliance.
We also decided that the Plan does not have to pre-approve continued BiPAP use after the three months if compliance criteria are not met.
The Plan follows Medicare rules. Medicare rules say that objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. Adherence to therapy is defined as use of PAP greater than or equal to four (4) hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage 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 continued BiPAP and humidifier use. Our reviewer says that the documentation supports that the BiPAP approval should be extended for three months to allow more time to achieve tolerance and compliance. Our physician reviewer found you have severe obstructive sleep apnea (OSA) but have been struggling with mask fit, leak, and tolerance. You also changed sleep specialists recently. The records document significant efforts on your part to try to achieve mask fit and tolerance since the diagnosis of OSA in May of this year. The clinical note from September 1, 2021 indicates a new interface being tried. BiPAP approval should be extended for three months to allow more time to achieve tolerance and compliance. If compliance criteria are not met (at least 70% of days with at least four hours/day) at that point, the device will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of unlimited continued BiPAP use has not been met. Therefore, we decided that the Plan does not have to pre-approve continued BiPAP use after the three months if compliance criteria are not met.