Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve three (3) additional months of a home ventilator. We decided that 
the Plan does not have to pre-approve continued use of a home ventilator after the 3 months.  
 
 You asked the Plan to pre-approve continued use of a home ventilator (E0466).. You say that you have been 
having personal issues with depression which were preventing you from having any planned sleep periods and 
you have not been using your device. You also say you have resolved most of those issues and have been 
compliant since receiving notice of the denial. The Plan says that the request is not medically necessary 
because the documentation does not support that this device meets but does not exceed your need. Your records 
do not demonstrate that you have failed treatment with a BiPap, and it is unclear how your current noninvasive 
ventilator is being used. 
 
We decided that the Plan has to pre-approve three (3) additional months of a home 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 use of a home ventilator 
(E0466). Our reviewer says that the service is partially medically necessary. Our physician reviewer found the 
current device should be approved for an additional 3 months to allow time for transition to BiPAP.  You have 
very severe obesity with a BMI of 68.4, and obstructive sleep apnea. A diagnosis of obesity hypoventilation 
syndrome is listed, based on previous hospitalizations for hypercarbic respiratory failure.  You have previously 
been on CPAP and BiPAP. BiPAP was prescribed after a PAP titration study in October 2021. The ventilator 
was prescribed in April 2022, following a hospitalization in which you had prolonged mechanical ventilation 
following abdominal surgery. Compliance data from April 9 to May 8, 2023, show usage of the device for at 
least 4 hours daily of 23% of days. Pulmonary function tests show moderate restrictive lung disease. Therefore, 
we decided that the Plan has to pre-approve three (3) additional months of a home ventilator.  
 
We also decided that the Plan does not have to pre-approve continued use of a home ventilator after the 
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 continued use of a home ventilator 
(E0466). Our reviewer says that the service is not medically necessary. Our physician reviewer found there is 
no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. You have obesity 
hypoventilation syndrome. BiPAP is the appropriate treatment for OHS, and the records do not show that this 
treatment has failed. Medicare does not cover a home ventilator for the treatment of OHS, or when used at 
settings that could be provided with BiPAP. You indicate in an appeal note that compliance issues with the 
ventilator have been related to depression and medical issues and you expect to be able to use the device more 
consistently. Therefore, we decided that the Plan does not have to pre-approve continued use of a home 
ventilator after the 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.