Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Failure

Treatment: Durable medical equipment (DME) - E0483RR x 3, cough assist device

The insurer denied coverage for durable medical equipment (DME) - E0483RR x 3, cough assist device.

The denial is overturned.

The patient required resection of a hemangioma of the spine. He developed spinal cord injury affecting the cervical 3rd, 4th and 5th nerves. This resulted in quadriplegia, the need for a tracheostomy. The tracheostomy was subsequently removed but he continues to require feedings through a gastro-jejeunal feeding tube. 

The patient had a recent hospitalization for respiratory failure, and he had to be intubated and mechanically ventilated for respiratory failure. Following his recovery and the removal of the endotracheal tube he developed respiratory distress related to atelectasis of the lung which improved following a bronchoscopy. He has hypoventilation due to muscle weakness and his cough is weak. He required treatment with BIPAP [bilevel positive airway pressure] when sleeping. He also requires daily treatment with symbicort, pulmozyme and hypersaline nebulizer treatments.

Since manual chest physical therapy has been attempted and not considered a viable option to improve his airway clearance his pulmonologist has ordered the cough assist device and the InCourage Vest therapy for treatments in the home to prevent ongoing respiratory problems.

The insurer has denied the approval of the InCourage Vest indicating that manual chest physical therapy and positive expiratory pressure (PEP) devices should be used for this patient.  The InCourage high frequency chest wall oscillator system is considered medically necessary.

The patient has a history of hypoventilation, muscle weakness and an ineffective cough which resulted in atelectasis and the need for a bronchoscopy to recover. Patients with a cervical spine injury and subsequent quadriplegia are at risk to recurrent respiratory infections due to an inability to clear airway secretions. These patients benefit from daily chest physical therapy to help mobilize secretions and avoid recurrence of respiratory infections. Airway clearance is an essential treatment that improves the quality of life and long-term outcome for children with muscle weakness to avoid recurrent lung disease and infections. 

The medical record indicates that the father has been instructed in how to perform adequate daily chest physical therapy and that this patient cannot adequately perform airway clearance with a PEP device. The InCourage Vest therapy and the cough assist device are considered the most appropriate level of service and it is known to be effective therapy which has been shown to decrease airway infections and hospitalizations and to improve health outcomes for children with muscle weakness and an inability to clear airway secretions due to a weak cough. 

The medical record does support the need for ongoing daily treatment with the cough assist device and Vest therapy. The InCourage Vest would be appropriate for a patient with quadriplegia and risk for respiratory failure due to recurrent respiratory infections. 

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

The insurer's denial of coverage for durable medical equipment (DME) - E0483RR x 3, cough assist device is overturned. Medical Necessity is substantiated.