Pneumatic Vest denials: what the review data shows

Where the denial was overturned

Physician 1The patient is an eight-year-old male who has pulmonary complications due to cerebral palsy. The patient has undergone gastrostomy. The patient’s provider and parents report it has been difficult to deliver chest physiotherapy (CPT). In addition, the patient continued to experience complications even with twice a day therapy. The submitted information indicates the patient has undergone a trial of the Vest Airway Clearance System (the Vest System) with good results. The Health Plan had denied coverage for the Vest System on the basis it is considered investigational for patients such as this patient.In view of the patient’s history of spasticity, gastrostomy, and frequent pulmonary infections, use of the Vest System is medically appropriate and indicated. The Vest System has been shown to be effective for patients such as this patient who cannot undergo postural drainage.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Flexitouch Plus pneumatic compression device for head and neck. Head and neck therapy is associated with damage to lymphatic structures that results in secondary lymphedema. This is particularly true with chemoradiation treatments which are a mainstay therapy in head and neck cancers. Secondary lymphedema is associated with functional losses including range of motion and even swallowing along with discomfort and a sense of disfigurement due to changes in the anatomy of the neck. Some patients report recurrent infections as well. The standard treatment for secondary lymphedema is complete decongestive therapy with manual lymphatic drainage massage, education, exercise, compression, and skin care.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for high frequency chest wall oscillation air pulse generator for treatment of the enrollee who has a history of asthma and Down’s syndrome. Findings: 2/3 of the physician reviewers found that there is minimal evidence that the use of chest wall percussive devices benefit patients with non-cystic fibrosis bronchiectasis. There are indications for a high frequency chest wall oscillation system including cystic fibrosis, bronchiectasis, or neuromuscular disorder with inability to clear secretions. While this patient has recurrent infections per the documentation provided, there is no evidence that the patient has underlying bronchiectasis, cystic fibrosis or a neuromuscular disorder that alters airway clearance.

Nature of Statutory Criteria/ Case Summary: The enrollee’s representative is requesting reimbursement for InCourage Airway Clearance Therapy high frequency chest compression device (E0483). The enrollee has a history of cerebral palsy, Down syndrome, blindness, deafness, developmental delay, and seizures. His provider is requesting coverage for the InCourage Airway Clearance Therapy high frequency chest compression device (E0483). The enrollee’s provider indicates the enrollee is entirely dependent on others for his care and has a history of hospitalizations for respiratory illness. He has a continued need for a chest percussion device that keeps him from getting bronchitis and pneumonia. The enrollee also suffers from gastroesophageal reflux disease, (GERD) and recurrent aspiration pneumonia. He is treated with Keppra and recurrent antibiotics.

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 Pneumatic Vestwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.