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 overturned.

The patient is an adult female who has a history of severe persistent asthma. At issue is the health plan denial of authorization for bronchial thermoplasty. According to notes from the patient's physician, the patient has severe persistent asthma that is mildly responsive to Tezspire. Her other medications 
at that time included Arnuity Ellipta, Montelukast, Asmanex hydrofluoroalkane (HFA), Fluticasone, Breztri Aerosphere and albuterol. The patient was also taking alprazolam for anxiety. Despite these medications, she continued to be triggered by odors and other factors to have asthma attacks. She had previously been treated with Xolair, Nucala and Fasenra, 
reportedly without success. A computed tomography (CT) of the chest was normal some years ago. The patient was seen a facility and was noted to have muscle tension dysphonia. Lung function tests some years ago showed a forced vital capacity (FVC) of 2.44 liters (69 percent predicted), forced expiratory volume in one second (FEV1) of 2.38 liters (79 percent predicted) and forced expiratory volume in one second (FEV1) / forced vital capacity (FVC) of 97 percent. Lung function tests from some years ago showed a forced vital capacity (FVC) of 3.90 liters (111 percent predicted), forced expiratory volume in one second (FEV1) of 3.35 L (111 percent predicted) and forced expiratory volume in one second (FEV1) / forced vital capacity (FVC) of 86 percent. After administration of an inhaled bronchodilator, forced expiratory volume in one second (FEV1) improved to 3.72 L (123 percent, +11 percent). Lung function tests last year were unremarkable. Forced vital capacity (FVC) was 4.11 liters (117 percent predicted), forced expiratory volume in one second (FEV1) was 3.68 liters (123 percent predicted) and forced expiratory volume in one second (FEV1) / forced vital capacity (FVC) was 89 percent with no significant bronchodilator response. Bronchial thermoplasty was considered due to her severe ongoing symptoms and frequent need for corticosteroids.
An affidavit in support of the patient's request from her husband, indicated that the patient had mild asthma since childhood that had become more severe from some years ago. She had prolonged exposure to formaldehyde gas at that time, with subsequent severe asthma attacks several times a day. These attacks made her feel short of breath, with chest tightness and exhaustion. The condition has left her chronically ill, homebound and with difficulty performing activities of daily living.
Most recently the patient was treated for difficult to control severe persistent asthma with reports of worsening dyspnea. Triggers included something as simple as perfumes or odors during cooking. She often required steroid tapers to control symptoms. It was noted that the patient does not have a contraindication to bronchial thermoplasty such as a presence of a pacemaker or internal defibrillator or other implantable electronic devices. 

The health plan should cover the proposed treatment.

Bronchial thermoplasty should be considered in patients with severe persistent asthma who are unsuitable for and/or failed other treatments (i.e., immunotherapy, Xolair, etc.). Bronchial 
thermoplasty (BT) is no longer considered an experimental treatment. The Food and Drug Administration has approved marketing of the Alair Bronchial Thermoplasty System for the 
treatment of adult patients (greater than or equal to [>=] 18 years old) with severe asthma poorly controlled with inhaled glucocorticoids and long-acting beta agonists. (1-5) Although some exacerbations of asthma may be expected initially, several controlled trials have demonstrated long-term benefit for this treatment (6-8).