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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the bronchial thermoplasty for treatment of the enrollees persistent asthma. Findings:  The physician reviewer found that according to the patients provider, the patient has poorly controlled severe persistent asthma with frequent exacerbations requiring systemic steroids. The patient is already on maximal conventional therapy for bronchial asthma including inhaled steroids and long-term beta-agonists, Breo Ellipta, leukotriene inhibitor, montelukast, and even parenteral therapy with monoclonal antibody, Xolair. In addition, the patient has developed side effects with use of systemic steroids and is still symptomatic daily and has frequent exacerbations of her bronchial asthma. This is precisely the type of patient for whom bronchial thermoplasty has been used and found to be useful. Bronchial thermoplasty is has been approved by the U.S. Food and Drug Administration (FDA) and has been endorsed for use in specific populations of patients with bronchial asthma by organizations such as the American College of Chest Physicians and the American College of Allergy, Asthma and Immunology. This patient meets the current criteria for severe refractory asthma as indicated in the medical records and providers letter. Despite maximal treatment for bronchial asthma, the patient is still symptomatic and has stopped or limited her activities of daily living and have developed complications of the use of frequent courses of oral steroids to control her exacerbations. The patient has been properly evaluated for other causes to explain her symptoms and her pulmonary function tests are compatible with obstructive lung disease. All told, the requested radio waves procedure (bronchial thermoplasty) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.