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

Physician 1The patient is an eight-year-old male who has pulmonary complications due to cerebral palsy. The patient has undergone gastrostomy. The patients provider and parents report it has been difficult to deliver chest physiotherapy (CPT). In addition, the patient continued to experience complications even with twice a day therapy. The submitted information indicates the patient has undergone a trial of the Vest Airway Clearance System (the Vest System) with good results. The Health Plan had denied coverage for the Vest System on the basis it is considered investigational for patients such as this patient.In view of the patients history of spasticity, gastrostomy, and frequent pulmonary infections, use of the Vest System is medically appropriate and indicated. The Vest System has been shown to be effective for patients such as this patient who cannot undergo postural drainage. It is likely the patients condition will worsen without use of the Vest System. Therefore, 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 2The patient is an eight-year-old male with cerebral palsy. The patients parents indicate the patients spastic movements and gastrostomy tube make chest physical therapy difficult. The patients provider has recommended use of the Vest Airway Clearance System (the Vest System). The Health Plan has denied coverage for the Vest System on the basis it is considered investigational for treatment of patients with cerebral palsy.There are no long-term, randomized, controlled, clinical trials that document the safety and efficacy of use of the Vest System in this patient population. As such, the Vest System is of unknown value for patients with cerebral palsy. The Vest System is a high frequency chest wall device for chest physical therapy and has been available since 1988. It has been studied most frequently in patients with cystic fibrosis where daily chest physical therapy is generally accepted, medically necessary treatment. There has been no documented superiority of the Vest System over routine chest physical therapy in any disease entity where the end point of the clinical trial is a clinically significant outcome endpoint such as: fewer hospitalizations for pulmonary infections, decrease of length of hospitalization or decrease in the progression of a pulmonary disease. Based upon the information set forth above, 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 3The patient is an eight-year-old male with cerebral palsy. The submitted records document pulmonary complications. The patient is status post gastrostomy. The patients provider and parents report it has been difficult to deliver chest physiotherapy (CPT). In addition, the patient continued to experience complications even with twice a day therapy. The submitted information indicates the patient has undergone a trial of the Vest Airway Clearance System (the Vest System) with good results. The Health Plan had denied coverage for the Vest System on the basis it is considered investigational for patients such as this patient.Review of the submitted records indicates the patient has failed conventional methods of secretion clearance. The patient experiences frequent pulmonary infections. Standard CPT has not been effective as it is difficult to administer given the patients spasticity. Additionally, as noted by the patients provider, the patient has a gastrostomy tube and therefore, is at greater risk for aspiration during CPT. The Vest System has been shown to be effective for patients such as this patient who cannot undergo postural drainage. Furthermore, the patients provider notes the patient has been cooperative with the Vest System and his parents are able to administer the treatments without difficulty. As such, it appears the Vest System is superior to standard secretion clearance modalities available to this patient.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. Therefore, the Health Plans denial should be overturned