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

Physcian 1: The patient is a 55-year-old woman with hypogammaglobulinemia and bronchiectasis.  She has been well treated by established methods with limited success.  However, with The Vest therapy she has noted better and more efficient expectoration and improved quality of life. There is no spirometric evidence of improvement provided, but her steroid dose has been reduced.  The Health Plan denied authorization and coverage for The Vest based upon their determination that it is investigational for the treatment of bronchiectasis.As the standard therapies have been tried with limited success and The Vest seems to be successful and practical, it is appropriate that the patient continue with this treatment.  Spirometric evidence of improvement is not essential.  The Vest is a reasonable method of airway clearance in a bronchiectatic patient when other known and more accepted methods are no longer effective.  Therefore, I have determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physcian 2: The patient is a 55-year-old female with hypogammaglobulinemia and subsequent bronchiectasis. According to the patient, she has tried various methods of secretion clearance including chest physiotherapy, IPV and nebulizers. She states that use of The Vest has improved her symptoms.  A letter from the treating pulmonologist indicates the patient has been on rotating antibiotics, bronchodilators, continuous oxygen and steroids. He has prescribed various methods of secretion clearance including chest physiotherapy (CPT), the Flutter device and IPV. The physician also states that since starting The Vest, the patient has had clinical improvement.The Health Plan denied coverage of The Vest on the basis that it is considered investigational. There are many studies to support the theory that enhancing mucus clearance in patients with bronchiectasis is beneficial in disease control and symptom management. Common methods include the use of CPT, postural drainage and mucolytic agents.  The patient has tried various methods of secretion clearance including use of bronchodilators, CPT and the Flutter device. She was also on rotating antibiotics, supplemental oxygen and systemic steroids. Secretion clearance is paramount in the management of bronchiectasis as it prevents infections and improves symptoms. The patient is unable to receive consistent CPT because her husband works long hours.According to the submitted evidence, the patient has a need for airway clearance and there is documentation of the failure of other methods or the inability to use other methods. The use of The Vest is medically appropriate and indicated in the treatment of this patient.Based upon the information set forth above, I have determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 55-year-old female with a 25-year history of hypogammaglobulinemia and bronchiectasis. The records document frequent exacerbations and the need for antibiotics and steroids. Traditional airway clearance therapies are no longer successful for her. Her husband is not available for percussion, and she has difficulty with the Flutter valve device. The patient is requesting authorization for The Vest Airway Clearance System, which was deemed investigational by the Health Plan and therefore denied.Use of The Vest oscillation system is now considered the standard of care for patients with severe bronchiectasis who fail other airway clearance methods. The patient meets criteria for use of high-frequency chest compression. She is diagnosed with bronchiectasis, has failed other methods of airway clearance and her age is greater than two years.  Furthermore, high-frequency chest compression is generally not considered experimental nor is it investigational for the treatment of bronchiectasis.Based upon the information set forth above, I have determined that the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.