Vest Airway Clearance System 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.

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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for vest airway clearance system for treatment of the enrollee who was diagnosed with recurrent acute lower respiratory infection.Findings: Three physician reviewers found that the patient had a diagnosis of mild upper lobe bronchiectasis and multiple pulmonary nodules. The patient has been treated with the Acapella device. The patients pulmonary function tests were normal and stable. Diffusion capacity per alveolar volume was also normal. Total lung capacity was normal. Oxygen (O2) saturation on room air at rest was 98% and with exertion to a heart rate of 151 per minute, the O2 saturation on room air was 95%. Her chest was clear. There was no ground glass lesions. The computed tomography scan of the chest did not have bronchiectasis of the lingula or right middle lobe.

The enrollee is requesting authorization and coverage for vest airway clearance system. The enrollee has a history of pulmonary fibrosis, bronchiectasis, and chronic obstructive pulmonary disease. He requires chest physical therapy to clear secretions and currently does not have a caregiver to perform it. The enrollee’s advocate reports consistent, aggressive airway clearance is necessary for the enrollee to maintain his pulmonary function. Retention of secretions can lead to chronic inflammation and progressive lung damage, with the possibility of developing resistance to standard treatment. Medical records did not demonstrate this enrollee had a continuous, productive cough for more than six months. Records do not demonstrate that this enrollee experienced frequent exacerbations, more than two, in the last year which required treatment with anti-infective medications.

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 Vest Airway Clearance System, then check the rights and deadlines that apply to your plan.