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 a bilevel positive airway pressure 
(BiPAP) will not meet the enrollee's medical needs. The Plan says that this request for continued use of a 
noninvasive ventilator (NIV) 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 for an additional 3 
months. Our reviewer says that the current device should be extended 3 months to allow time for transition to 
BiPAP. Our physician reviewer found that there is no evidence in the medical record that the enrollee was tried 
on BiPAP as an outpatient. The enrollee was discharged with a home ventilator in the average volume-assured 
pressure support (AVAPS) mode from their hospitalization in January 2023. This enrollee would likely benefit 
from BiPAP with 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 beyond an additional 
3 months. Our reviewer says that a home ventilator is not medically necessary beyond the three approved 
months. Our physician reviewer found there is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. Pulmonary function tests on March 15, 2023, showed a forced expiratory volume in 1 second (FEV1) 
of 58% of predicted with a normal FEV1/forced vital capacity (FVC) ratio and a reduced total lung capacity, 
with no evidence for air trapping. Our reviewer found that this indicates moderate restrictive disease. There are 
no arterial blood gas (ABG) tests done while stable to document chronic carbon dioxide retention. Our 
physician reviewer also found that although the enrollee would likely benefit from BiPAP with AVAPS during 
sleep, 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.