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 of 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to chronic obstructive pulmonary disease (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 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). This enrollee's respiratory needs could be met with 
BiPAP with average volume-assured pressure support (AVAPS), with a backup rate. 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. The current device should be approved for 3 months to allow time 
for transition to BiPAP with AVAPS. 
 
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 of the ventilator. 
 
The Plan follows Medicare rules. Medicare 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 chronic obstructive pulmonary disease (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 continuation of 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). This enrollee's respiratory needs could be met with 
BiPAP with average volume-assured pressure support (AVAPS), with a backup rate. 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. The current device should be approved for 3 months to allow time 
for transition to BiPAP with AVAPS. 
 
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 of the ventilator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of 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.