Bronchitis 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage of urgent care services. Findings: The physician reviewer found that though the initial services at issue were not required on an emergent or urgent basis, taking into context the patient’s underlying health condition supports that a prudent layperson in this circumstance would reasonably believe urgent care services were necessary to prevent serious deterioration of the his health. At issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services for emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for DME - Volara System and supplies. Findings: The physician reviewer found that Lee and colleagues report that patients with bronchiectasis experience chronic cough and sputum production and require the prescription of airway clearance techniques. Mucus clearance programs are the mainstay of treatment of bronchiectasis. While the Volara System assists in mucus clearance, there is insufficient evidence to support the use of the Volara System over alternative standard mucus clearance programs including those combining flutter valves, hypertonic saline, nebulizer bronchodilators, and/or vest therapy. Per the medical evidence, airway clearance systems such as the Volara System appear comparable to other airway clearance techniques, including vest therapy.

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 bronchitis, then check the rights and deadlines that apply to your plan.