Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Vest Airway Clearance System. 
The insurer denied the Vest Airway Clearance System. 
The denial is upheld in whole. 

This is the case of a male who was involved in a motor vehicle accident with traumatic brain injury. The patient has epilepsy and severe cognitive impairment. The patient has increase in airway secretions and impaired airway clearance. The patient has difficulty swallowing, excessive mucus production and recurrent pneumonia. The patient is on Atrovent twice a day. The patient uses the Scopolamine patch to decrease excessive oral and airway secretions. The treating provider is requesting the coverage of Vest airway clearance system to maximize his lung function and prevent future infection. 

No, the requested health service/treatment of the Vest Airway Clearance System is not medically necessary for this patient. 

Retained airway secretion can at least in theory lead to bacterial superinfection and eventually pneumonia. Chest physical therapy and gravitational positioning should be effective if followed assiduously and done by experts. The Chest percussion techniques include hand clapping of the chest by an assistant or application of a mechanical vibrator to the chest wall, or application of a vest with an external vibrator. When physiotherapy is performed regularly three to four times daily, enhanced sputum mobilization occurs in many patients. 

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. 

The Vest has been studied mainly in patients with cystic fibrosis (CF) with bronchiectasis. For non-cystic fibrosis patients requiring assisted clearance of secretions, information on high frequency chest compression is very limited. There is no evidence that the Vest will be of any use in patient with excessive airway secretion. There is in particular no evidence that the Vest will be of help to prevent recurrent pneumonia in patients with difficulty to clear the airways from retained secretion. 

Many of the studies of high frequency chest compression reviewed have quality issues including small sample size, lack of proper control for confounding variables such as illness severity, and limited follow-up. Based on limited data, all of the studied airway clearance modalities seem to be relatively comparable in terms of mobilizing sputum and occurrence of adverse effects. 

This patient has history of traumatic brain injury and excessive airway secretions. He has difficulty getting rid of his sputum and oral secretions. Clearing the airways from the retained secretion should be of help in theory to improve the patient clinical condition and decrease the risk of recurrent pneumonia. However, there is no clear evidence to prove that the Vest can achieve such outcome in this patient. There are no long term trials on the safety and efficacy of the Vest in patient with difficulty to clear the airway from retained secretion in patients with traumatic brain injury. There is no evidence that the Vest improve the overall outcome in such patients. The computed tomography (CT) scan did not show any convincing evidence of diffuse bronchiectasis. The patient does not have history of CF or neuromuscular disease. 

Based on Milliman care guidelines, in absence of cystic fibrosis and / or bronchiectasis the Vest role in the management of various respiratory diseases continues to be uncertain. Evidence is insufficient, conflicting, or poor and demonstrates an incomplete assessment of net benefit vs harm; additional research is recommended to establish role of the ultimate role of the Vest. 

Based on all the above discussion, it is not medically necessary.