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

Physician 1: The patient is a 55-year-old female with apparent recurrent bronchitis (bronchiectasis), and chronic obstructive pulmonary disease (COPD), resulting in respiratory failure. In addition, the patient has pancreatic insufficiency. There is no mention in the submitted records as to whether the diagnosis of cystic fibrosis has been ruled out. The patient is using the Vest Airway Clearance System (the Vest System) to help raise secretions. Based upon the information provided, it is not known if she has tried the Accapella device or the Flutter valve. The Health Plan has denied coverage for the Vest System on the basis it is considered investigational.The clinical information provided does not support the use of the Vest System by this patient. Though the patient does require a method for secretion clearance, the submitted records do not document which methods have been tried and failed. The patient may benefit from use of the Flutter valve or other modalities. There is insufficient information regarding the patients use of standard modalities to warrant the use of the Vest System by this patient. Therefore, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 55-year-old female with the following diagnoses: bronchiectasis, COPD, chronic pancreatitis, and chest pain. The patient requires supplemental oxygen and receives daily antibiotic treatment. Current medications include cefepime, tobramycin, albuterol, Spiriva, Imdur, pancrease, Lasix, Tikosyn and prednisone. The patient also uses a BiPAP machine for obstructive sleep apnea. Her physician initiated therapy using the Vest Airway Clearance System (the Vest System). He also noted improvement in breath sounds and improvement in her shortness of breath since starting the Vest System. The Health Plan indicates use of the Vest System by this patient is considered investigational.There are many studies to support that enhancing mucus clearance in patients with bronchiectasis (specifically, cystic fibrosis) results in a benefit in disease control and symptoms. These include use of chest physiotherapy, postural drainage and mucolytics. An article by Hansen, et al. found no improvement in frequency of hospitalizations in cystic fibrosis patients using HFCC devices, but did see an improvement in the flow rates. Secretion clearance is paramount in the management of bronchiectasis as it prevents infections and improves symptoms. Though the documentation provided does not indicate the patient has been tried on alternative methods of secretion clearance such as the Flutter device, based on her decreased pulmonary capacity as noted by her physician, she probably would not be able to generate the necessary airflow needed with a Flutter device. Furthermore, she is unable to receive CPT because she does not have a consistent caregiver. Thus, the use of the Vest System is medically reasonable and appropriate and, in fact, has been effective for the patient to date.Based upon the information set forth above, I have determined that the requested equipment 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 who has requested authorization for the Vest Airway Clearance System (the Vest System). The patients underlying condition is bronchiectasis. Additionally, the patient has severe pulmonary hypertension complicated by chronic pancreatitis as well as recurrent chest pain. Her current management includes oxygen therapy; additionally, she is on suppressive daily oral antibiotic therapy and receives bronchodilator therapy. Despite the above standard care, the patient is unable to cough and effectively mobilize her secretions. She has had prior hospitalizations secondary to bronchitis and retained secretions. Unfortunately, physical therapy is not an option for the patient as she does not have a caregiver consistently available to administer percussion. The patient has undergone a trial of the Vest System, which has resulted in improvement in airway function secondary to clearance of secretions. The Health Plan indicates the benefit of the Vest System for treatment of bronchiectasis has not been proven superior to standard therapies.Though use of oscillatory devices such as the Vest System are considered experimental except for use in cystic fibrosis, it is known that these devices generally increase sputum delivery. The data indicates the HFCC device (such as the Vest System) yielded a mean volume of cleared mucus of 3.3 cc per session, compared with 1.8 cc for a conventional therapy session.Intuitively, improved mobilization of secretions would appear to be beneficial regardless of whether the patient has bronchiectasis and/or cystic fibrosis. Both conditions are associated with significant retention of secretions. An article by Langenderfer, et al. indicates the particular needs of the patient determine which modality will be most effective. In the case of this patient, she has no full-time caregiver, she is clearly incapacitated and there is no dispute over diagnoses or the fact that she has retained secretions. Furthermore, the information provided indicates the patient has clinically improved with mobilization of secretions by the Vest System. For these reasons, I have determined that the requested equipment 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.