Diagnosis: Chronic obstructive pulmonary disease; chronic hypercapnic respiratory failure.
Treatment: Home Ventilator.

The insurer denied the Home Ventilator. The denial is overturned.

The patient is an adult female with severe chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure. She has been prescribed a non-invasive home ventilator (NIV). The patient is on Trelegy Ellipta, prednisone and Duonebs for chronic obstructive pulmonary disease (COPD). For hypercapnic respiratory failure the patient has tried and failed bi-level positive airway pressure (BIPAP) 10/5. The non-invasive home ventilator is denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment was medically necessary.

This patient with severe chronic obstructive pulmonary disease (COPD) with chronic hypercapnic respiratory failure is prescribed a non-invasive home ventilator (NIV). The patient is on Trelegy Ellipta, prednisone and Duonebs for chronic obstructive pulmonary disease. For hypercapnic respiratory failure, the patient has tried and failed bi-level positive airway pressure 10/5. Despite being on bi-level positive airway pressure, the patient continues to have daytime hypercapnia.

Chronic non-invasive ventilation (NIV) has become evidence-based care for stable hypercapnic chronic obstructive pulmonary disease patients. In acute settings non-invasive ventilation is beneficial as a first-line intervention in conjunction with usual care for reducing the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD). The magnitude of benefit for these outcomes appears similar for patients with acidosis of a mild (potential of hydrogen [pH] 7.30 to 7.35) versus a more severe nature (potential of hydrogen less than 7.30), and when non-invasive ventilation (NIV) is applied within the intensive care unit (ICU) or ward setting. According to European Respiratory Society, "Managing hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients." The non-invasive ventilator, Trilogy ventilator at home, is medically necessary, as the patient has tried and failed the alternative machine, bi-level positive airway pressure.