Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Asthma
Treatment: Bronchial Thermoplasty (Codes 31660 and 31661)
The insurer denied: Bronchial Thermoplasty (Codes 31660 and 
31661)
The denial is upheld.

The patient is an adult female with history of asthma - severe persistent. Her current medications include Breztri, Arnuity, Singulair, and as needed (PRN) albuterol. She is also on 
Tezspire. The patient was exposed to formaldehyde when she was working as a production manufacturer in a plastic manufacturing facility. She was told to stop working - around three years ago. Prior to this, she was diagnosed with asthma with minimal flare up requiring rescue inhaler. Since then - most triggers are smell or fumes or hot weather. She does get short of breath during a shower and exposure to her neighbors grilling in the backyard. No other trigger factor is mentioned. The patient gets short of breath and has chest pain. There is no documentation of cough or wheeze or chest tightness.
During the time frame of some years ago, the patient was on Advair 250/50, Spiriva with as needed albuterol, and Flonase nasal spray twice a day (BID). During the time frame from last year, the patient was on Breztri, Arnuity, Singulair, Flonase nasal spray and as needed albuterol. The latter part of last year, the patient was on Tezspire. The last steroid burst documented was some years ago requiring prolonged course. There is recommendation to use steroids around some months ago when she had exposure to lint from dryer cleaning but there is no documentation if she took it. There is no documentation that the patient requires daily rescue inhaler or has night awakening. Her medication is increasing but on the current medication, there is no documentation in clinic note about her symptoms not being controlled. The patient has had normal pulmonary function tests (PFTs) in for the past some years; normal chest x-ray last year; and computed tomography (CT) of the chest without contrast some years ago. Her eosinophil count is 110 and immunoglobulin E (IGE) was normal. 
Radioallergosorbent test (RAST) was normal. The patient has been seen by an ear, nose, and throat (ENT) physician for dysphonia some years ago - she had a normal laryngoscope. Ear, nose and throat (ENT) impression after videostroboscopy was that there was no evidence of vocal cord (VC) dysfunction during quit breathing or deep breathing. He recommended therapy for muscle tension dysphonia, but the patient declined. The patient had a second opinion for bronchial thermoplasty. The note mentions the patient had methacholine challenge test at age of 14. The result is not documented. The physician recommended holding off on bronchial thermoplasty.
The patient has been seen by an Allergy and Asthma physician some years ago - it was documented the patient was using rescue albuterol five to six times per week with no nocturnal symptoms. 
Impression was that it was not allergy mediated but reactive airway or hypersensitivity reaction. The reason for denial is that the health plan considers bronchial thermoplasty experimental and investigational. The reason for appeal is to consider bronchial thermoplasty.

The health plan should not cover the proposed treatment.

There have been no adequate and well controlled investigations/studies published involving long-term bronchial thermoplasty use in severe asthma. Safety of long-term use of bronchial thermoplasty has not been established. Although there is increasing data supporting its short-term effectiveness, bronchial thermoplasty has not been fully embraced by the medical community, due to (I) the challenges associated with categorizing patients with severe asthma in the daily clinical practice; (II) the difficulty of identifying the correct patient phenotype who will benefit the most from this procedure; and (III) the lack of understanding of the complex mechanism of action that bronchial thermoplasty exerts beyond the medium size airways. 
Therefore, based on submitted documentation, the bronchial thermoplasty is experimental and investigational.