Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 3 additional months of continued use of a NIV device. We decided 
that the Plan does not have to pre-approve 96 additional months of continued use of a NIV device.  
 
 
 You asked the Plan to pre-approve continued use of a NIV. You say that you are in need of the requested 
durable medical equipment because it is keeping you alive. It is also stated that without the equipment, you are 
unable to breathe, and your lungs will fill with CO2. The Plan says that the request for continued use of non
invasive ventilator (NIV) is not medically reasonable and necessary. The documentation indicates that this 
device is being used solely for pressure support, and thus it is being used solely as a respiratory assist device. 
There is no supporting documentation that this NIV is being used as intended. 
 
We decided that the Plan has to pre-approve 3 additional months of continued use of a NIV device.  
 
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. 
 
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 use of a noninvasive 
ventilator. Our reviewer says that the service is partially medically necessary. Our physician reviewer found 
you have severe COPD and apparently have had a home ventilator since a hospitalization in 2022. A home 
ventilator is not medically necessary, although your current device should be approved for an additional 3 
months to allow time for transition to BiPAP. At that time, an arterial blood gas was consistent with acute 
hypercarbic respiratory failure. Therefore, we decided that the Plan has to pre-approve 3 additional months of 
continued use of a NIV device. 
 
We also decided that the Plan does not have to pre-approve 96 additional months of continued use of a 
NIV device. 
 
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. 
 
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 use of a noninvasive 
ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found you 
have severe COPD and apparently have had a home ventilator since a hospitalization in 2022. There is no ABG 
done while stable to document chronic CO2 retention. If that is present, you may benefit from BiPAP with 
AVAPS during sleep. The records do not show that this has been tried and failed as an outpatient. 
Medicare does not cover a home ventilator when used at settings that can be provided with BiPAP. Therefore, 
we decided that the Plan does not have to pre-approve 96 additional months of continued use of a NIV 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.