Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees asthma. Findings:  The physician reviewer found that the data supports the short and long term benefits of bronchial thermoplasty for patients with severe asthma. However, in this patients case, it is uncertain what this patients asthma regimen encompasses. The documented medications include a combination of rescue inhalers, which typically controls most asthmatics. Further, it appears if the patients predominant issue is dyspnea and pleuritic chest pain, an uncommon presentation in asthma that is reported to be unimproved in the face of steroids. There is a single indication that her regimen was expanded to include an antimuscarinic (Spiriva) and a Leukotriene antagonist, both common medications to trial in refractory asthmatics. However, there is no record of an IgE level or consideration of using Xolair (omalizumab), a proven immunotherapy for severe refractory allergic asthma with a documented elevated IgE. Prior to considering bronchial thermoplasty for refractory asthma, these noted medications should be trialed. Finally, and unique to this patient, is her history of inflammatory bowel disease, an illness often times with extraintestinal manifestations. Pulmonary findings can include interstitial lung disease, bronchiectasis, pulmonary thromboembolic disease, obliterative bronchiolitis, pleural disease and organizing pneumonia. The pulmonary manifestations have been found to occur in patients even with well controlled gastrointestinal disease. Further, the mesalamine the patient is maintained on for control of her inflammatory bowel disease can have a number of idiosyncratic and well described pulmonary side effects, including pleuritis. Along with expansion of the patients asthma regimen and evaluation of an IgE level, a gastroenterology evaluation should be considered as an alternative treatment regimen to the mesalamine. In sum, the requested bronchial thermoplasty is not likely to be more effective than the other standard methods of treating this patients medical condition. Final Result: Two of three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.