The American Association for Homecare (AAHomecare) and the ALS Association are continuing their collaborative work on the issue of Medicare Advantage (MA) plans unfairly restricting coverage for non-invasive ventilation (NIV) devices.
In an Oct. 13 update, AAHomecare said it partnered with the ALS Association to discuss these concerns with the Centers for Medicare & Medicaid Services (CMS).
An Oct. 4 letter sent by the associations to Kathryn Coleman, CMS’s Director, Medicare Drug & Health Plan Contract Admin. Group, said, “Physicians are prescribing NIV devices for their critically ill patients with ALS and other diagnoses that meet the National Coverage Determination (NCD) requirements. These patients routinely receive NIV devices from private payers and Medicare Fee-for-Service.
“However, MA plans are ignoring physicians’ orders and instead use excessive prior authorization requirements, requiring ‘fail first’ on Respiratory Assistance Devices (RAD) for patients that need an NIV device and, in some instances, outright denying NIV to ALS patients. Their strategies are focused on saving dollars and not on what is medically necessary.”
The letter pointed out that research has shown that NIV produces better outcomes and reduces costs for Medicare beneficiaries. “So, it is especially frustrating that MA Plans are denying coverage for NIV devices — resulting in the needless deaths of beneficiaries while also increasing costs to the Medicare program through preventable exacerbations and hospital admissions,” the letter said.
The Difference Between NIV and RADs
The letter also noted that MA plans cannot provide an E0471 RAD instead of an E0466 (NIV) without the prescribing physician’s approval. “Each medical device has different capabilities, provides different therapies, and these differences are critical to achieving optimal clinical outcomes for patients with ALS and chronic respiratory failure,” the association said in the letter. “Physicians know NIV and RADs are not equivalent or interchangeable devices. When a physician prescribes NIV, they are making a medical determination based on a physical examination of the patient along with specific pulmonary function test as well as their expert understanding of ALS and their knowledge of a specific device.”
The associations noted that NIV devices “are more powerful and more capable than RADs,” and pointed out that NIV devices “are required to have back-up batteries and disconnection alarms,” features that the physician is expecting when writing the NIV prescription.
“More importantly, NIV devices are manufactured with more powerful turbines than RADs so that they can provide the high rate of airflow that is the heart of mechanical ventilation,” the letter said. “NIV devices are about twice as powerful as RADs. This is important because the latest and best clinical research demonstrates that higher pressures are generally associated with better outcomes.”
Different Devices for Different Conditions
And the two devices are FDA approved to treat different conditions, the letter added. “NIVs are designed and FDA approved to treat chronic respiratory failure. RADs are designed and FDA approved to treat sleep apnea.
“Research supports NIV for chronic respiratory failure. Since 2020, peer-reviewed, real-world studies have been published showing that NIV use significantly reduces mortality and healthcare spending in Medicare patients with chronic respiratory failure. However, there is no evidence to support RADs are achieving these same merits.”
The letter was written as a formal response to the CMS review of the issue, and was signed by Kathleen Sheehan, Vice President Public Policy, ALS Association; Cynthia Knoche, Director, Chapter Care Services, ALS Association; Tom Ryan, President/CEO, AAHomecare; and David Chandler, Senior Director Payer Relations, AAHomecare.