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 continuation the ventilator.  
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan says that 
based on the documentation provided, coverage criteria have not been met. 
 
 We decided that the Plan has to pre-approve a ventilator for 3 months.  
 
The Plan follows Medicare rules. Medicare rules say that the decision to use a ventilator or a bi-level positive 
airway pressure device is made based upon the specifics of each persons medical condition. 
 
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 reviewer 
says that the services are medically necessary. Our physician reviewer found continuation of the home 
ventilator is not medically necessary, although approval should be extended 3 months to allow time for 
transition to bilevel positive airway pressure (BiPAP). It appears this enrollee's needs could be met with BiPAP 
with average volume-assured pressure support (AVAPS) with a backup rate during sleep as an outpatient. The 
records do not document 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 an 
additional 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 continuation the ventilator. 
 
The Plan follows Medicare rules. Medicare rules say that the decision to use a ventilator or a bi-level positive 
airway pressure device is made based upon the specifics of each persons medical condition. 
 
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 continuation the ventilator. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found continuation of the 
home ventilator is not medically necessary, although approval should be extended 3 months to allow time for 
transition to bilevel positive airway pressure (BiPAP). It appears this enrollee's needs could be met with BiPAP 
with average volume-assured pressure support (AVAPS) with a backup rate during sleep as an outpatient. The 
records do not document 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 an 
additional 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 continuation the ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation the 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.