Name:

Address:

DOB:

Member ID:

To Whom It May Concern, 

I am requesting a fast appeal on the above patient ______________________. Due to the severity of the patient’s disease, bi-level pap devices have been proven ineffective at managing this patient’s hypercapnia. This patient requires a mode of non-invasive ventilation similar to AVAPS-AE to achieve adequate ventilation. Interruption or failure to provide NIV would quickly lead to exacerbation of the patient’s condition, hospital admission, and likely harm or death to the patient. The patient requires frequent durations of respiratory support and deteriorates quickly in the absence of non-invasive ventilation. 

Ordering Physician:_________________________

NPI #: _______________________________

Date: _____________________

Name:

DOB:

Member ID:

Date:

To Whom It May Concern, 

I am requesting an expedited pre-authorization for my patient _______________________. Non invasive ventilation similar to AVAPS-AE is a life sustaining mode and is medically necessary to prevent chronic respiratory failure. Interruption of respiratory support could quickly lead to serious harm and or death.

Ordering Physician: ________________________Physician Signature: ________________________

NPI #: _______________________________

Date: ____________________________

Name:

DOB:

Date:

Member ID:

To Whom It May Concern,

This letter serves as a letter of medical necessity for non-invasive ventilation with modes similar to AVAPS-AE. ______________________, is treated for chronic respiratory failure secondary to chronic obstructive pulmonary disease. BIPAP has been tried and failed and has proven the patient requires an NIV mode like AVAPS-AE to achieve adequate ventilation. The patient requires volume ventilation due to the severity of this patient’s disease state and life-threatening condition like carbon dioxide retention. Due to the increased probability of exacerbation, the patient requires a controlled target ventilation via face mask to prevent hospital admissions and death. The NIV will be used every night during sleep as well as on an as needed basic for naps and increased shortness of breath. 

In my professional opinion, utilization of non-invasive ventilation in this patient will improve outcomes and reduce emergency room visits and hospital admissions in the future.

Sincerely, 

Ordering Physician: ________________________

Physician Signature: _______________________

NPI#: __________________________________

Date: ___________________________

Name:

DOB: 

Date:

Member ID:

To Whom It May Concern,

Home NIV ordered due to COPD and chronic respiratory failure. BIPAP/ BIPAP ST are deemed inappropriate therapies for the patient due to providing target tidal volumes via breath-by-breath auto-adjusting pressures. Home NIV does provide these patient specific settings and will deliver pressures within precise parameters that the COPD progression demands. The therapy will not only reduce the chronic Co2 retention (even while wearing BIPAP) but it will also allow the patient to remain stable in the home and out of the inpatient setting. We will educate on the usage and benefits of the NIV ventilator through our dedicated respiratory therapist and compliance will be reported back to my office. 

Ordering Physician: ________________________

Physician Signature: __________________________

NPI: _______________________________

Date: ______________________________