Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a ventilator for three months. We decided that the Plan does not 
have to pre-approve a ventilator beyond three months if there is no evidence of diaphragmatic weakness after 
three months. 
 You asked the Plan to pre-approve a ventilator. You say that you disagree with the Plan's denial. The Plan says 
that the requested device is not medically necessary. 
 
We decided that the Plan has to pre-approve a ventilator for three months.  
 
The Plan follows Medicare rules. Medicare rules say that a ventilator is covered for certain indications. 
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 ventilator. Our reviewer says that the 
documentation supports that the requested ventilator is medically necessary for three months in order to allow 
time for additional testing. Our physician reviewer found the enrollee was recently hospitalized with sepsis and 
acute renal failure due to obstructive uropathy.  The enrollee has diagnoses of COPD and spinal muscular 
atrophy, and is wheelchair bound.  However, there are no pulmonary function tests or inspiratory mouth 
pressures to document either COPD or diaphragmatic weakness. Arterial blood gas (ABG) tests in the hospital 
were consistent with acute on chronic hypercarbic respiratory failure. The hospital notes suggest the enrollee 
had difficulty tolerating bilevel positive airway pressure (BiPAP) in the hospital. This enrollee's acute on 
chronic carbon dioxide retention may be related to diaphragmatic weakness from neuromuscular disease. If that 
is the case, a home ventilator is necessary in order to provide noninvasive ventilatory support during sleep, and 
sip and puff ventilation during waking hours, as well as alarms and battery backup. This is approved for three 
months in order to allow time for additional testing. If pulmonary function testing confirms severe reduction in 
the forced vital capacity and reduction in negative inspiratory force, a home ventilator will continue to be 
necessary. 
 
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 ventilator have been met. Therefore, we decided that the Plan has to pre-
approve a ventilator for three months.  
 
We also decided that the Plan does not have to pre-approve a ventilator beyond three months if there is 
no evidence of diaphragmatic weakness after three months. 
 
The Plan follows Medicare rules. Medicare rules say that a ventilator is only covered for certain indications.  
 
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 ventilator beyond three months. Our 
reviewer says that the documentation supports that the requested ventilator is medically necessary for three 
months in order to allow time for additional testing. Our physician reviewer found the enrollee was recently 
hospitalized with sepsis and acute renal failure due to obstructive uropathy. If there is no evidence of 
diaphragmatic weakness after the three-month trial, the enrollee's ventilatory assist needs could be met with 
BiPAP with AVAPS during sleep, which is not covered.  
 
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 ventilator beyond three months. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a ventilator beyond three 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.