Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an additional three (3) months of a non-invasive ventilator. We 
decided that the Plan does not have to pre-approve an additional nine (9) months of a non-invasive ventilator.  
 
 You asked the Plan to pre-approve continued use of a non-invasive ventilator for twelve (12) months (E0466). 
You say that you disagree with the denial and request reconsideration. Medical records have been submitted for 
review. The Plan says that the request for continued use of a noninvasive ventilator is not medically 
reasonable and necessary. The documentation indicates that this device is being used solely for AVAPSAE 
mode, and thus it is being used solely as a respiratory assist device. 
 
We decided that the Plan has to pre-approve an additional 3 months of a non-invasive ventilator.  
 
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 non-invasive 
ventilator for twelve (12) months (E0466). Our reviewer says that the service is medically necessary. Our 
physician reviewer found the enrollee has a diagnosis of COPD and has had a home ventilator since 2019. A 
home ventilator is not medically necessary, although the enrollees current device should be approved for an 
additional 3 months to allow time for transition to BiPAP. Therefore, we decided that the Plan has to pre-
approve an additional 3 months of a non-invasive ventilator. 
 
We also decided that the Plan does not have to pre-approve an additional 9 months of a non-invasive 
ventilator. 
 
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 non-invasive 
ventilator for twelve (12) months (E0466). Our reviewer says that the service is not medically necessary. Our 
physician reviewer found the enrollee has a diagnosis of COPD and has had a home ventilator since 2019. It 
appears this enrollees respiratory support needs could be met with 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 an additional 9 months of a non-invasive ventilator. 
 
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.