Bronchial Thermoplasty 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested bronchial thermoplasty for treatment of his medical condition. Findings: Two physician reviewers found that initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial by Cox and colleagues examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up. The RISA study by Pavord and colleagues examined the safety of thermoplasty and found short term worsening in symptoms, but evidence of improved long term control of asthma. Finally, the AIR2 trial by Castro and colleagues compared thermoplasty with a sham procedure and followed the patients out for 12 months as well.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollee’s asthma. Findings: The physician reviewer found that the data supports the short and long term benefits of bronchial thermoplasty for patients with severe asthma. However, in this patient’s case, it is uncertain what this patient’s asthma regimen encompasses. The documented medications include a combination of rescue inhalers, which typically controls most asthmatics. Further, it appears if the patient’s predominant issue is dyspnea and pleuritic chest pain, an uncommon presentation in asthma that is reported to be unimproved in the face of steroids. There is a single indication that her regimen was expanded to include an antimuscarinic (Spiriva) and a Leukotriene antagonist, both common medications to trial in refractory asthmatics.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollee’s asthma. Findings: 2/3 of the physician reviewers found that although, bronchial thermoplasty has been U.S. Food and Drug Administration (FDA) approved for the treatment of severe persistent asthma, based on the review of current peer-reviewed literature, the quality of literature available is poor in regards to objective evidence of therapeutic benefits, as well as long-term safety and efficacy. The majority of literature available shows only modest improvement in quality of life and lower rates of asthma exacerbation. The literature fails to show evidence that bronchial thermoplasty provides significant benefits in asthma control scores.

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