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| Medical Policy: | S-70-010 |
| Topic: | Bronchial Thermoplasty |
| Section: | Surgery |
| Effective Date: | July 23, 2018 |
| Issue Date: | July 23, 2018 |
| Last Reviewed: | May 2018 |
Bronchial thermoplasty is the controlled delivery of radiofrequency energy to heat tissues in the distal airways with the aim of decreasing smooth muscle mass believed to be associated with airway inflammation. The thermal energy delivered via bronchial thermoplasty aims to reduce the amount of smooth muscle and thereby decrease muscle-mediated bronchoconstriction with the ultimate goal of reducing asthma-related morbidity. Bronchial thermoplasty is intended as a supplemental treatment for patients with severe persistent asthma (i.e., steps 5 and 6 in the stepwise approach to care). |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Bronchial thermoplasty may be considered medically necessary as an adjunctive therapy in the management of severe persistent asthma when ALL of the following coverage criteria are met:
- The individual is 18 years of age or older; and
- Individual has been managed for at least three (3) months by an asthma specialist (allergist, pulmonologist or a physician with special expertise in asthma); and
- Has chronic, severe persistent asthma (Step 5 or 6 by National Heart, Lung, and Blood Institute (NHLBI)/National Asthma Education and Prevention Program (NAEPP) guidelines) which includes:
- Use of inhaled steroids for at least three (3) consecutive months; and
- Current use of long-acting BETA agonists or leukotriene inhibitors for at least three (3) consecutive months; and
- Conventional asthma therapy has been ineffective or not tolerated (e.g., individual has had two (2) or more acute attacks, emergency room visits, or hospitalizations in the past 12 months); or
- Conventional asthma therapy has been ineffective or not tolerated with continued poor quality of life (e.g., daily asthma symptoms (e.g., coughing, wheezing, chest tightness, shortness of breath, congestion), nighttime awakenings with asthma symptoms, use of rescue inhalers multiple times a day or limitation of activity, loss of work or schooling due to asthma symptoms); and
- Individual is either using chronic oral steroids or chronic oral steroids is being considered to control asthma symptoms; and
- Has a forced expiratory volume in one (1) second ( FEV1) greater than 50% predicted by American Thoracic Society (ATS) criteria; and
- Is a non-smoker for at least one (1) year or a total smoking history of less than 10 pack years; and
- The individual is either not a candidate (e.g., non-allergic phenotype, normal IgE levels, cannot tolerate side effects or allergy) or is refractory to a trial of anti-IgE therapy or anti-Interleukin (Il)-5 therapy; and
- Individual does not have ANY of the following co-morbid conditions:
o Gastroesophageal reflux disease; or
o Chronic aspiration; or
o Severe allergies; or
o Vocal cord dysfunction.
Bronchial thermoplasty for any other indication or when the above criteria are not met is considered experimental/investigational as the safety and efficacy has not been substantiated by peer reviewed literature.
Bronchial thermoplasty beyond the initial three (3) treatment sessions is considered experimental/investigational as the safety and efficacy has not been substantiated by peer reviewed literature.
| Place of Service: Outpatient |
Bronchial thermoplasty is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
07/2018, Coverage Criteria Established for Bronchial Thermoplasty
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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