Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a home ventilator for an additional 3 months. We decided that the 
Plan does not have to pre-approve a home ventilator beyond an additional 3 months.  
 
You asked the Plan to pre-approve a home ventilator (E0466). You say that without non-invasive ventilator 
(NIV) therapy, the enrollee is at high risk for hospital admission and potentially life-threatening exacerbations. 
The Plan says that the request for continued use of a device to assist with breathing (noninvasive ventilator or 
NIV) coded as E0466 does not meet the requirements for approval. 
 
We decided that the Plan has to pre-approve a home ventilator for an additional 3 months.  
 
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 home ventilator should be approved for an additional 3 months to allow successful transition to bilevel 
positive airway pressure (BiPAP). There is no evidence in the medical record that the enrollee was tried on 
BiPAP as an outpatient. The enrollee was prescribed a home ventilator upon discharge from the 2022 
hospitalization, and has been using it with excellent compliance. This enrollee would likely benefit from 
BiPAP with average volume-assured pressure support (AVAPS) as an outpatient. 
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 for an additional 3 months have been met. Therefore, we 
decided that the Plan has to pre-approve a home ventilator for an additional 3 months.  
 
We also decided that the Plan does not have to pre-approve a home ventilator beyond an additional 3 
months. 
 
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 home ventilator is not medically necessary beyond the three approved months. There is no diagnosis of 
thoracic restrictive disease or neuromuscular disease. During hospitalization in July 2022, for congestive heart 
failure and exacerbation of COPD, there was mild CO2 retention with a partial pressure of carbon dioxide 
(PaCO2) of 52. This normalized to 44.6 later in the hospitalization. Although the enrollee would likely benefit 
from BiPAP with AVAPS as an outpatient, Medicare does not cover a home ventilator in the treatment of 
obesity hypoventilation syndrome, or when used at settings that can be provided with BiPAP. 
 
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 beyond an additional 3 months have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a home ventilator beyond an additional 3 months. 
 
 
 
 
 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.