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.

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.

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.

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.

• Link to Provider Resource Center for the Medical Policy Update

07/2018, Coverage Criteria Established for Bronchial Thermoplasty

• Link to Diagnosis Codes

• Link to References