Bronchiectasis denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 55-year-old female with apparent recurrent bronchitis (bronchiectasis), and chronic obstructive pulmonary disease (COPD), resulting in respiratory failure. In addition, the patient has pancreatic insufficiency. There is no mention in the submitted records as to whether the diagnosis of cystic fibrosis has been ruled out. The patient is using the Vest Airway Clearance System (the Vest System) to help raise secretions. Based upon the information provided, it is not known if she has tried the Accapella device or the Flutter valve. The Health Plan has denied coverage for the Vest System on the basis it is considered investigational.The clinical information provided does not support the use of the Vest System by this patient.

Physcian 1: The patient is a 55-year-old woman with hypogammaglobulinemia and bronchiectasis. She has been well treated by established methods with limited success. However, with The Vest therapy she has noted better and more efficient expectoration and improved quality of life. There is no spirometric evidence of improvement provided, but her steroid dose has been reduced. The Health Plan denied authorization and coverage for The Vest based upon their determination that it is investigational for the treatment of bronchiectasis.As the standard therapies have been tried with limited success and The Vest seems to be successful and practical, it is appropriate that the patient continue with this treatment. Spirometric evidence of improvement is not essential.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vest airway clearance system for treatment of the enrollee who was diagnosed with recurrent acute lower respiratory infection.Findings: Three physician reviewers found that the patient had a diagnosis of mild upper lobe bronchiectasis and multiple pulmonary nodules. The patient has been treated with the Acapella device. The patients pulmonary function tests were normal and stable. Diffusion capacity per alveolar volume was also normal. Total lung capacity was normal. Oxygen (O2) saturation on room air at rest was 98% and with exertion to a heart rate of 151 per minute, the O2 saturation on room air was 95%. Her chest was clear. There was no ground glass lesions. The computed tomography scan of the chest did not have bronchiectasis of the lingula or right middle lobe.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with mild bronchiectasis, which was confirmed by computed tomography (CT) scan of the chest. The records document chronic obstructive pulmonary disease. He has had two episodes of acute exacerbation of his bronchiectasis with an increase in productive cough. His symptoms reportedly improved with antibiotics. The patient’s provider recommended utilizing airway clearance techniques to manage his sputum production. The patient was determined by his provider not to be a candidate for manual chest physiotherapy and postural drainage due to the lack of a care provider who could assist him with this type of therapy. The patient has requested authorization and coverage for a high-frequency chest wall oscillation system.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving bronchiectasis, then check the rights and deadlines that apply to your plan.