Diagnosis: respiratory complications

Treatment: second home ventilator

The insurer is denied coverage for second home ventilator

The denial is overturned.

This female patient has a history of chronic respiratory failure and tracheostomy and ventilator dependent secondary to rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation disease.

In this patient there were significant abnormal apneic episodes of 25 seconds in the polysomnography (PSG) tracheostomy cap trial. This clearly indicates that patient is dependent on the assisted ventilation all the time and particularly sleep time. The patient has significant autonomic deficits and hence the compensatory mechanism after hypopnea nor apnea is not discernible clinically hence patient needs EtCO2 (end tidal carbon dioxide) and SpO2 (oxygen saturation) to monitor the respiration and ventilation. Patient needs a uninterrupted ventilatory support and a second trilogy ventilator is essential for sustenance of life. Even if there is back up battery for the first ventilator, if the first ventilator breaks down, the patient needs a functional second ventilator to back up respiratory function, ready within minutes. The durable medical equipment (DME) company will or may take hours to days to rectify the malfunction. Due to the risk of mortality and morbidity in absence of adequate ventilator back up, the second ventilator is essential. Hence denial is reversed.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for second home ventilator is overturned. The medical necessity is substantiated.