Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis. 
Treatment: Airway clearance device. 

The insurer denied coverage for airway clearance device. 

The denial is modified. 

This is a child with a complex medical history and bronchiectasis. The child had dilated cardiomyopathy and subsequently required a heart transplant. He then developed post-transplant lymphoproliferative disease and B-cell lymphoma. He also has obstructive sleep apnea and requires nightly nocturnal BIPAP [bilevel positive airway pressure] at a pressure of 11/5. The patient receives daily treatment with Tacrolimus, prednisone, Asmanex and 3% (percent) hypertonic saline. He has been off inhaled TOBI [tobramycin] and three times a week azithromycin. He has been using the Vest therapy for the past years because of the presence of bronchiectasis. The patient was last seen by Pediatric Pulmonary a few months ago. He has a mixed restrictive and obstructive pattern on his pulmonary function testing. His chest x-ray indicates the presence of increased lung markings. 

Per UpToDate article Cystic fibrosis (CF) and Bronchiectasis: Overview of the treatment of lung disease: 

"Chest physiotherapy - All patients who produce sputum should be encouraged to use some form of chest physiotherapy for secretion clearance. This recommendation is based upon the recognition that retained purulent secretions are an important cause of airflow obstruction and airway injury in CF, and longstanding clinical practice, despite the lack of strong evidence from clinical trials [33-35]. Adherence to chest physiotherapy is often poor, particularly among patients with mild disease [36,37]. 

A variety of techniques may be used for chest physiotherapy, and there is no evidence that they differ in efficacy [38,39]. Because patients vary in their acceptance and preference for different modes, several techniques should be introduced to each patient. Methods that can be performed without assistance from another person should be offered, to allow patients to have more control over their regimen. The cost of equipment should be considered, with less expensive modalities prescribed first. More expensive apparatus such as percussion vests may be appropriate for those patients who fail to clear secretions with less expensive methods, who report that the more expensive modalities are effective for them, and who remain adherent with their use. 

Airway Clearance 

Physiotherapy 

Daily airway clearance with cardiovascular exercise, use of percussion vests, manual chest physical therapy and valve/positive pressure expiratory devices help mobilize and aid expectoration of broncho-pulmonary secretions, improve efficiency of ventilation, maintain/improve exercise tolerance and reduce breathlessness." (1) 

The patient has a complex medical history and bronchiectasis. He has been stable with ongoing daily vest therapy and has been able to be weaned off chronic respiratory treatments with TOBI and azithromycin. There is no history of any recent respiratory illness related to his bronchiectasis. Airway clearance is an essential treatment for patients with bronchiectasis to help prevent recurrent respiratory infections. The vest therapy appears to be helping the patient who has not had any recent respiratory infections or the need for hospitalization. 

Vest therapy and bronchiectasis should require ongoing consultation with a Pediatric Pulmonologist to monitor the compliance and benefit of ongoing therapy. The coronovirus pandemic may have resulted in the patient's inability to be seen for routine follow up by Pediatric Pulmonary. The vest therapy should be continued for the next few months to allow the patient an opportunity to be seen by the Pediatric Pulmonologist who will review the necessity for ongoing treatment with the vest. 

The medical record does support the need for ongoing daily treatment with the vest high frequency airway clearance device for a period of three months to allow time for this patient to be seen in consultation by the Pediatric Pulmonologist. 

The health plan acted reasonably, in part, and with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for an airway clearance device is modified. Medical necessity is partially substantiated.