Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiectasis.
Treatment: Vest airway clearance system.

The insurer denied the Vest airway clearance system.  The denial is upheld.

The patient is a female, who suffers from sarcoidosis and bronchiectasis. The treating provider is requesting the treatment with the Vest airway clearance system. The patient has productive cough. The patient symptoms improved while on the Vest. The subject under review is the medical necessity for the Vest airway clearance system.

The requested treatment with the Vest airway clearance system is not medically necessary for this patient.

This patient suffers from mild bronchiectasis. The review of the available documents did not show any objective and convincing evidence in term of progress note and office visit note that the patient failed standard therapy for the treatment of bronchiectasis.  Therefore, the requested Vest is not indicated for this patient at this time.

Bronchiectasis is an acquired disorder of the major airways that is characterized by permanent abnormal dilatation and destruction of the airways walls. The affected areas show a variety of changes including inflammation, edema and distortion due to scarring or obstruction from repeated infection. 

The classic clinical manifestations of bronchiectasis are cough and the daily production of mucopurulent and tenacious sputum lasting months to years. Mucus can collect in the airways and is difficult to clear with possibility of super-infection that will lead eventually to a vicious circle of more inflammation and more destruction of the lung.

Treatment of bronchiectasis is aimed at controlling infection and improving bronchial hygiene. Since infection plays a major role in causing and perpetuating bronchiectasis, reducing the microbial load is a cornerstone of therapy. Cleaning the airways from retained secretion should in theory help meeting this goal.

Chest physical therapy and gravitational positioning should be effective if followed assiduously and done by experts. Alternatives for patients who cannot perform chest physiotherapy include the Vest, a positive expiratory pressure device, which facilitates secretion drainage by maintaining airway patency, or a flutter device that enhances sputum clearance by generating oscillatory positive airway pressure.

A Cochrane review concluded that more data are needed to establish the clinical value of airway clearance techniques (ACTs) over the short and long term on patient-important outcomes, including symptoms, on physiological outcomes which may clarify the rationale for each technique and on long-term parameters that impact on disease progression in individuals with stable bronchiectasis.

According to Snijders et al., there is a lack of randomized controlled trials regarding the effect of airway clearance techniques (ACTs) in non-cystic fibrosis bronchiectasis (nCFb) patients. Moreover, none of the studies describes long-term effects of ACTs. There is no evidence to recommend or contest any type of ACTs in nCFb management.

This patient has history of bronchiectasis. Clearing her airways from the retained secretion should be of help in theory to improve her clinical condition and decrease the risk of recurrent pneumonia. However, there is no clear evidence to prove that the Vest can achieve such goal in a patient with bronchiectasis over standard therapy.