In a newsletter, AAHomecare (AAHC) announced it and the ALS Association met with the Centers for Medicare & Medicaid Services (CMS) Part C leadership to share concerns about ongoing authorization challenges for medically necessary non-invasive ventilator (NIV) devices by Medicare Advantage (MA) payers. Access to these ventilator systems is especially important for individuals with significant neuromuscular diseases such as ALS.
AAHomecare’s Tom Ryan, David Chandler and General Counsel Cara Bachenheimer were joined by ALS Association representatives Kathleen Sheehan, VP of public policy, and Cynthia Knoche, director of chapter care services. Lisa Wolf and John Hansen-Flaschen, prominent physicians who treat ALS patients, also took part in the meeting with the CMS deputy director, Parts C and D, as well as the CMS director and deputy director of Drug and Health Plan Contact Administration.
AAHomecare and the ALS Association shared their alarm at reports of increasing denials as high as 86% and 64% for two major plans, while other plans have denial rates in the low teens. Authorization issues are being seen for both new set-ups as well as for continued authorizations where patients have benefitted from NIV.
The ALS Association representatives and clinicians provided first-hand accounts of the devastating impacts that delays and denials can have on patients and their caregivers. The advocates drove home the notion that physicians who have examined and made a clinical assessment of a patient are best positioned to determine the type of respirator needed – not MA plan prior authorization and utilization staff.
AAHomecare and the ALS Association asked CMS to promptly issue a memorandum clarifying medical policy and coverage of non-invasive ventilators and take steps to expedite NIV authorizations for people living with ALS.
AAHC said it will be following up with its request in writing and was encouraged by the willingness of CMS to work with the patient community, physician community and AAHomecare to resolve this critical issue.
"AAHomecare and our patient advocacy allies are determined to make sure that MA plans conform to statutory requirements to follow Medicare coverage guidelines," read the release. "We will continue to engage policymakers at all levels to ensure that people who need life-sustaining respiratory therapies—and every other HME product and service—have appropriate access under applicable federal and state coverage rules."
