Stakeholders push back against vent denial rates 

WASHINGTON – With an “absurd” denial rate as high as 86% for non-invasive ventilators for one major Medicare Advantage plan, industry stakeholders are collaborating with patient advocacy groups to elevate their concerns with CMS. 

Confusion around who qualifies for NIVs vs. bi-level devices is nothing new, but recently, it’s gotten worse, says David Chandler, senior director of payer relations for AAHomecare. 

“It’s escalated to what I consider a blatant disregard for vulnerable patient populations who meet that objective criteria and still experience delays or denied access to NIV,” he said. “But, if there’s no other option – this patient can’t tolerate the bi-level and they meet the coverage criteria – why is this authorization being denied?” 

In June, AAHomecare and the ALS Association met with CMS and asked the agency to issue a memorandum clarifying medical policy and coverage of NIVs, as well as to take steps to expedite authorizations for people living with ALS. During the meeting, stakeholders shared reports of denials as high as 86% and 64% for two major MA plans, with rates in the low teens for other MA plans. They reported issues for both new setups and continued authorizations.  

Craig Douglas says he’s seen denials even when prior authorizations were approved in the past for ongoing need, and examples of payers trying to downgrade the patient to a bi-pap device on AVAPS mode. 

“We’re talking about patients with ALS getting denied with no real rhyme or reason, although I assume some are still getting approved,” says Douglas, vice president of payer relations for VGM & Associates. “We’ve got stories of providers that, ultimately, said, ‘We can’t put the patient on (the device) you are telling us to.’” 

Stakeholders are gathering specific examples of MA plans being more restrictive in their coverage than traditional Medicare and spearheading a data gathering project on prior authorization denials, says Chandler. 

“I would encourage suppliers to track authorization denials and look for trends as well as continue to advocate for patients by pushing back on denials through appeals where they meet objective clinical criteria,” he said. “An 80% denial rate is absurd.”