Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis (reactive airway disease)
Treatment: High Frequency Chest Wall Oscillation System
The insurer denied the high frequency Chest Wall Oscillation System.  
The denial has been overturned. 

The proposed treatment is medically necessary.

The patient is a pediatric female. The service under review is high frequency chest wall oscillation system (HFCWOS). This service was denied as not medically necessary and this decision is being appealed.

The patient's medical history includes DiGeorge syndrome, bronchiectasis, bronchomalacia, ineffective cough, dysphagia, aspiration, chronic cough, respiratory infections, asthma, and gastroesophageal reflux disease (GERD). Chest computed tomography (CT) showed bronchiectasis and subsequently, the patient started treatment with high frequency chest wall oscillation system (HFCWOS), with good clinical response. Airway clearance with manual chest physical therapy (PT) and postural drainage is contraindicated due to history of gastroesophageal reflux disease (GERD) and aspiration.

According to the Food and Drug Administration (FDA), high-frequency chest wall compression devices are designed to promote airway clearance and improve bronchial drainage. They are indicated when external chest manipulation is the physician's treatment of choice to enhance mucus transport.

In a Medical Technology Impact Comparison of high-frequency chest wall compression (HFCWC) for diseases other than cystic fibrosis (CF), Hayes reviewed a total of 13 studies and concluded that high-frequency chest wall compression (HFCWC) may provide some therapeutic benefit in adult patients and in children with disorders of airway clearance not related to cystic fibrosis (CF). Positive but very limited evidence suggests that high-frequency chest wall compression (HFCWC) can also be effective and safe in children with non-cystic fibrosis diagnoses.

Nicolini et al. showed that use of high-frequency chest wall compression (HFCWC) led to a significant improvement in biochemical and functional respiratory tests as well as in the quality of life compared to the control group. The use of high-frequency chest wall compression (HFCWC) compared to chest physical therapy (CPT) also produced a significant improvement in blood inflammation parameter C-reactive protein (C-RP) (p 0.019), parameters of lung functionality associated with bronchial obstruction (forced vital capacity [FVC], forced expiratory forced volume within one second [FEV1]) (p 0.006 and p 0.001), and in dyspnea. 

A Cochrane review showed that in general airway clearance techniques, including high-frequency chest wall compression (HFCWC), were safe for individuals (adults and children) with stable bronchiectasis, and there may be improvements in sputum expectoration, selected measures of lung function and health-related quality of life.
McCool et al showed that chest physiotherapy, including postural drainage, chest wall percussion and vibration, and a forced expiration technique (called huffing), increase airway clearance as assessed by sputum characteristics (i.e., volume, weight, and viscosity) and clearance of the radioaerosol from the lung. Other devices that allow patients to achieve the same benefits derived from chest physiotherapy without the assistance of a caregiver may be as effective as chest physiotherapy in increasing sputum production.

Therefore, the requested service, High Frequency Chest Wall Oscillation System (HFCWOS), is medically necessary for this patient.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

According to the medical literature the requested service is medically necessary.