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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for high frequency chest wall oscillation air pulse generator for treatment of the enrollee who has a history of asthma and Downs syndrome. Findings:  2/3 of the physician reviewers found that there is minimal evidence that the use of chest wall percussive devices benefit patients with non-cystic fibrosis bronchiectasis. There are indications for a high frequency chest wall oscillation system including cystic fibrosis, bronchiectasis, or neuromuscular disorder with inability to clear secretions. While this patient has recurrent infections per the documentation provided, there is no evidence that the patient has underlying bronchiectasis, cystic fibrosis or a neuromuscular disorder that alters airway clearance. There is no evidence of an airway disorder (primarily bronchiectasis) without documentation of pulmonary function testing (evidence of airway obstruction) or chest imaging (evidence of recurrent infection). There is also a lack of documentation noting that basic techniques such as postural drainage were tried prior to use of chest wall percussive devices. A combination of medications, chest physiotherapy, cough assist accessories, plus special coughing positions and techniques should be attempted prior to using chest wall percussive systems. In sum, due to a lack of support in the medical literature for the requested equipment, the high frequency chest wall oscillation air pulse generator provided was not and is not likely to have been superior over other modes of therapy available for treating this patient.  Final Result: 2/3 of the reviewers determined that the requested equipment was not and is 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.