ABI Vest denials: what the review data shows

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 authorization and coverage for a high frequency chest wall oscillation (HFCWO) system. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee’s bronchiectasis.At issue in this case is whether the requested high frequency chest wall oscillation system is medically necessary for treatment of the enrollee’s medical condition.Bronchiectasis is a disease where the airways become inflamed and dilated, thus creating a fertile breeding ground for bacterial infections. Patients with bronchiectasis typically have a chronic cough and recurrent infections. Treatment for this includes antibiotics, hyperosmolar agents, anti-inflammatory agents and chest physical therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for a wearable cardioverter defibrillator (Zoll LifeVest) or treatment of the enrollee who has a history of hypertrophic cardiomyopathy. Findings: The physician reviewer found that The benefits of the wearable cardiac defibrillator (WCD) have been the subject of intensive study. Moreover, WCD has not been a proven benefit for newly diagnosed patients with cardiomyopathy. Guidelines of the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) do not support use of the WCD. Instead, the guidelines recommend permanent ICD after a waiting period of 45 to 90 days if potentially reversible causes are present but the WCD has not been proven beneficial in this situation. There is a lack of randomized trial, which have shown the benefits of WCD over and above that of optimized medical therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a LifeVest. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy, and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for ABI Vestwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.