Contributor: Profit Over People—Medicare Advantage Plans Are Denying Vital NIV Therapy Coverage

In my 25 years as a respiratory therapist, I have been proud to help seniors and people with disabilities get the home oxygen and non-invasive ventilation (NIV) care they need. Timely access to treatment is

Jhon Vargas | Image provided by author

vital, but each day, insurance companies put up systemic obstacles that jeopardize the lives of an exceptionally vulnerable patient population. Even when measured against the typically subpar standards of the average health insurer, this predicament goes beyond the norm and reaches a new depth of callousness.

A typical day for me consists of visiting doctors’ offices at the request of physicians, as well as setting up prescribed equipment for life-sustaining NIV and other devices for airway clearance in patients’ homes.

The patients I serve come from various racial and economic backgrounds, and most of them are older adults dealing with chronic obstructive pulmonary disease (COPD). Their severe health conditions require them to use NIV; for pulmonary patients, this is literally a lifeline. Today, more and more seniors are choosing Medicare Advantage (MA) plans that advertise promises of enhanced benefits. However, the fine print reveals potential coverage limitations, leaving patients stranded without essential care.

Case in point: MA plans administered by major insurers routinely deny NIV coverage. Since December 2022, I have witnessed a disturbing trend: even in cases where patients meet all Medicare requirements and provide all essential documentation, MA plans deny this medically necessary treatment, and these denials are on the rise. Appeals of NIV denials are summarily dismissed by insurers without exception.

In fact, some MA insurers are being scrutinized for denying critical care to MA beneficiaries based on the use of algorithms often at odds with physicians’ actual recommendations. In November of 2023, a class action lawsuit was filed against major MA insurers in US District Court in Minnesota, alleging illegal utilization of an algorithm in which the companies relied on it to “systematically deny claims” for critically ill elderly patients. In the lawsuit, the plaintiffs allege that insurers denied coverage to nursing home patients struggling to recover from debilitating illnesses, even though the insurers were aware the algorithm had high error rates.

Meanwhile, at-risk patients and their frustrated providers must endure the exhaustive bureaucratic process of multiple appeals, denials, and additional appeals. Exacerbating the issue, third-party contractors enlisted by Medicare wield the gavel of denial, citing alleged failure to adhere to Medicare guidelines. The repercussions are dire, with patients enduring repeated hospital readmissions due to their inability to receive NIV therapy.

In a harrowing case that epitomizes the struggle faced by many, one of my patients had been utilizing pulmonologist-prescribed NIV for 5 years under a traditional Medicare plan. However, persuaded by MA advertisements boasting financial incentives and additional benefits, the patient made the switch to an MA plan, only to be met with immediate denial of NIV coverage.

In yet another distressing case, a patient endured 7 grueling days in the hospital fighting to appeal the denial of their NIV, only to be met with further rejection of both NIV and physical therapy coverage in the end. Despite their unwavering efforts, the patient was forced to leave the hospital, only to find themselves readmitted just 5 days later with alarmingly low oxygen and high carbon dioxide levels.

The consequences of this extend beyond the personal cost of a person struggling to get enough NIV. Denials also translate into exorbitant costs, with the typical hospital stay for my patients' costing tens of thousands of dollars. Such financial strain not only burdens patients and their families but also strains an already overburdened healthcare system. If insurers are trying to save money by denying medically necessary care, they are failing – and Medicare’s most vulnerable patients are the ones who suffer the most.

I plead for MA reform so that access to life-saving treatments such as NIV is a fundamental right, not a privilege limited and restricted by a patient’s health insurer.

As we navigate the complexities of MA reform, I implore you to heed this call to action, standing in solidarity to dismantle systemic barriers and pave the way for a future where every individual, regardless of medical condition, has access to the care they need.

Author Information

Jhon Vargas is a respiratory therapist in Charlotte, North Carolina, who has 25 years of experience. He works at Medical Comfort Systems, where he helps set up home medical equipment for patients with severe respiratory and pulmonary conditions.