Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a ventilator for 3 months. We decided that the Plan does not 
have to pre-approve more than 3 months coverage of a ventilator.  
 
You asked the Plan to pre-approve a ventilator. The Plan says that the use of a BiPAP would meet your needs.  
 We decided that the Plan has to pre-approve a ventilator for 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 ventilator for 3 months. Our physician 
reviewer found that you have COPD, severe obesity, and obstructive sleep apnea. You were hospitalized in 
August 2022 with severe acute on chronic hypercarbic respiratory failure, requiring intubation. You were 
prescribed a home ventilator at that time. The records do not include pulmonary function tests to assess the 
severity of the COPD, or a device download with compliance data. It appears your respiratory support needs 
could be met with BiPAP. There is no evidence 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. The current device 
should be approved for 3 months to allow time for transition to 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 ventilator for 3 months have been met. Therefore, we decided that the Plan 
has to pre-approve a ventilator for 3 months.  
 
We also decided that the Plan does not have to pre-approve more than 3 months coverage of a 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 coverage of a ventilator. Our 
physician reviewer found that your respiratory support needs could be met with BiPAP. There is no evidence 
that this has been tried and failed as an outpatient. The current device should be approved for 3 months to allow 
time for transition to BiPAP.  Additional coverage of a ventilator is not medically 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 continued coverage of a ventilator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve more than 3 months coverage of a 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.