Dr Jeffrey Sippel Discusses CMS Ventilator Denials Impacting Patients With ALS

Industry stakeholders and patient advocacy groups are raising concerns with CMS due to high denial rates for non-invasive ventilators (NIVs) in Medicare Advantage plans.¹ Confusion regarding NIVs vs bilevel devices has worsened, leading to delays and denied access for patients who meet the criteria.

In an interview with the American Journal of Managed CareⓇ (AJMCⓇ), Jeffrey Sippel, MD, MPH, associate director of Inpatient Clinical Services, and associate professor of clinical medicine, Pulmonary Sciences and Critical Care Medicine Division, Department of Medicine Department of Clinical Informatics University of Colorado School of Medicine, discussed the implications of coming face-to-face with repeated denials for patients with amyotrophic lateral sclerosis (ALS).

Can you provide details about the cases where patients with ALS were denied ventilators?

Jeffrey Sippel, MD, MPH: We've had troubles with denials for probably the last 18 months, and United is definitely the leader of the pack. I want to give you one example that was perhaps one of my early introductions to the challenges that we were going to face. This is from about a year and a half ago, I had a patient who reported me to the state board, because the patient said, I told her that United Healthcare denied her support machine and United Healthcare told her no, we never denied the machine. Well, here's what United Healthcare told her, they said, it's not authorized. And so since I said it was denied she felt that I was not correct in my interpretation, and she reported me to the state board. We got it all straightened out but that was really kind of the tip of the iceberg on this one.

I have had, in the last 6 weeks, 2 patients that we've had to admit to the hospital because we could not get outpatient support arranged in timely fashion. And they were doing horribly. And they either needed outpatient support with an NIV-type device, or they needed to be admitted, and we couldn't get it arranged as an outpatient. So, those are a couple. It's always tough in this population, because they have such a high mortality rate anyway, a few pass away before– again, this is all within the last 3 months–a couple pass away before we could ever get outpatient support arranged. Those are some examples of the troubles that we're having due to delays in authorization for outpatient bilevel devices.

Can you explain the differences between the ventilator devices you’re referring to?

There are a couple types of devices out there. There are what we call NIV (non-invasive ventilation) devices, and there are also what are called RAD (respiratory assist devices), which might also be called BiPAP (bilevel positive airway pressure), or something akin to that. In reality, either type of machine might be appropriate, but the NIV devices can have dual settings instead of single settings. They can be used for more than 12 hours a day because the motors are designed to be used for more than 12 hours a day. There's also a greater supply of the NIV devices, whereas the BiPAP-type devices can also be used for people with sleep apnea. So, there's a greater consumption of those devices. Plus, there's been some recalls of them lately as well. So there are supply issues that favor the NIV devices. There are some technical issues that favor the NIV devices. But I will acknowledge that we get delays on both of these. We get denials on NIVs and we get delays on the bilevel devices.

Reference

Flaherty T. Stakeholders push back against vent denial rates. HME News. Published August 15, 2023. Accessed November 8, 2023. https://www.hmenews.com/article/stakeholders-push-back-against-vent-denial-rates