Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466).  
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is to be used for the 
treatment of respiratory failure. The enrollee is currently in the hospital she has tried and failed bipap. This is a 
device the provider wants the enrollee to have before discharge. The Plan denied your request. The Plan says 
Medicare does not cover ventilators used in this way. Medicare will cover a device called respiratory assist 
device that as advanced features and the plan will cover this when medically necessary. 
 
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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
chronic respiratory failure due to idiopathic pulmonary fibrosis. Provided records document that the home 
ventilator is being requested for use in average volume assured pressure support (AVAPS) mode with auto-
EPAP (AE) which could be provided by a bilevel positive airway pressure (BiPAP) device with AVAPS and a 
back-up rate. Provided records do not document trial and failure of a BiPAP device with AVAPS and a back-up 
rate. As stated in the Local Coverage Determination (LCD) 33800: "Ventilators fall under the Frequent and 
Substantial Servicing (FSS) payment category, and payment policy requirements preclude FSS payment for 
devices used to deliver continuous and/or intermittent positive airway pressure, regardless of the illness treated 
by the device. (Social Security Act 1834(a)(3)(A)). This means that products currently classified as HCPCS 
code E0465, E0466, or E0467 when used to provide CPAP or bi-level PAP (with or without backup rate) 
therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. A 
ventilator is not eligible for reimbursement for any of the conditions described in this RAD LCD even though 
the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode. Claims 
for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will 
be denied as not reasonable and necessary." The LCD requires: "There must be enough detailed information in 
the medical record to justify the treatment selected." Provided records in this case do not provide adequate 
detailed information to meet Medicare criteria for coverage of a ventilator as opposed to a BiPAP device with 
AVAPS and a back-up rate. 
 
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 not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).