Severe Persistent Asthma denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the bronchial thermoplasty for treatment of the enrollee’s persistent asthma. Findings: The physician reviewer found that according to the patient’s provider, the patient has poorly controlled severe persistent asthma with frequent exacerbations requiring systemic steroids. The patient is already on maximal conventional therapy for bronchial asthma including inhaled steroids and long-term beta-agonists, Breo Ellipta, leukotriene inhibitor, montelukast, and even parenteral therapy with monoclonal antibody, Xolair. In addition, the patient has developed side effects with use of systemic steroids and is still symptomatic daily and has frequent exacerbations of her bronchial asthma. This is precisely the type of patient for whom bronchial thermoplasty has been used and found to be useful.

A 49-year-old male has requested bronchial thermoplasty for treatment of severe persistent asthma. Findings: Three physician reviewers found that the patient is a former smoker, with a history of poorly controlled, severe, persistent asthma, fibromyalgia, hypercholesterolemia, depression, gastroesophageal reflux disease, sinus disease, and atopy. Bronchial thermoplasty, the third of a planned three treatments, has been requested by the patient and the patient’s provider to treat the patient’s asthma. The patient has undergone the thermoplasty procedure on two previous occasions. A third planned treatment is requested for the upper lobes. The patient is currently receiving inhaled bronchodilators, inhaled corticosteroids, as well as inhaled and oral corticosteroids for severe persistent asthma.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollee’s severe persistent asthma. Findings: The physician reviewer found that There is data supporting the benefits of bronchial thermoplasty for selected patients. In this patient’s case, his asthma symptoms are atypical, being strictly exertional dyspnea and without otherwise having a demonstrable trigger. Per the records, his methacholine is positive, and the immunoglobulin E (IgE) level and exhaled nitric oxide levels are elevated, pointing to some manner of allergic disease. This may account for his dyspnea. The documentation indicated that the patient was started on Xolair. However, the medical records do not reflect the effects of Xolair.

Nature of Statutory Criteria/Case Summary: An enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma. Three physician reviewers found that per Torrego and colleagues, bronchial thermoplasty for patients with moderate to severe asthma can provide a modest clinical benefit in quality of life and lower rates of asthma exacerbations. Wahidi and Kraft reported that bronchial thermoplasty is an option for patients with severe asthma who continued to be symptomatic despite maximum medical treatment. However, there is a paucity of randomized controlled trials on patients with severe persistent asthma who experience more than three exacerbations of asthma in one year. This patient’s records document frequent exacerbations to include at least four to five times per year.

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 severe persistent asthma, then check the rights and deadlines that apply to your plan.