Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 3 months of continued use of a NIV. We decided that the Plan 
does not have to pre-approve 9 months of continued use of a NIV.  
 
 You asked the Plan to pre-approve continued use of a NIV. You say that the enrollee needs the ventilator 
because of the backup battery, alarms, and option for secondary mode for ambulation and recovery features 
that a BiPAP does not provide. It is also stated that the enrollees current settings cannot be supported with a 
BiPAP with VAPS. The Plan says that the request for continued use of noninvasive ventilator (NIV) is not 
medically reasonable and necessary. The documentation indicates that this device is being used solely for 
AVAPSAE, and thus it is being used solely as a respiratory assist device. 
 
We decided that the Plan has to pre-approve 3 months of continued use of a NIV.  
 
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 NIV. Our reviewer 
says that the service is partially medically necessary. Our physician reviewer found the enrollee has a diagnosis 
of COPD and has had a home ventilator since December 2020. An echocardiogram indicates the enrollee also 
has pulmonary hypertension and right ventricular failure. There have been previous hospitalizations with blood 
gases consistent with acute on chronic hypercarbic respiratory failure. The enrollee has improved with BiPAP 
in the hospital in the past. Use of the current device from April 24 to May 23, 2023, shows 87% of days with at 
least 4 hours of use. The current device should be approved for an additional 3 months to allow time for 
transition to BiPAP with AVAPS. Therefore, we decided that the Plan has to pre-approve 3 months of 
continued use of a NIV.  
 
We also decided that the Plan does not have to pre-approve 9 months of continued use of a NIV. 
 
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 NIV. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the enrollee has improved with 
BiPAP in the hospital in the past. There are no pulmonary function tests to assess the severity of the COPD. 
Use of the current device from April 24 to May 23, 2023, shows 87% of days with at least 4 hours of use. 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 9 months of continued use of a NIV. 
 
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.