Harvard Pilgrim HealthCare Medical Policy

Bronchial Thermoplasty

Subject: Bronchial Thermoplasty

Background: Bronchial thermoplasty is a minimally invasive treatment that uses heat to weaken and partially destroy the airway during asthma attacks.

Authorization: Prior authorization is required for all bronchial thermoplasty treatment requested for members enrolled in commercial (HMO, POS, or PPO) products.

• A complete bronchial thermoplasty procedure is performed in three treatment sessions with a recovery period of 3 weeks or longer between sessions. One prior authorization will allow for 3 treatment sessions.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

Policy and Coverage Criteria: The Plan may authorize elective bronchial thermoplasty for Members 18 years of age or older with a confirmed diagnosis of asthma and when documentation confirms all of the following:

• Member has severe persistent asthma (symptoms throughout the day, symptoms most nights, normal activities are extremely limited by disease) with FEV1 ≥ 60% predicted; AND
• Asthma is poorly controlled despite adherence to maximum tolerated doses of inhaled corticosteroids (ICS) and long-acting beta antagonists (LABA) for at least 3 months with two or more exacerbations in the past 12 months as documented by one or more of the following:
  • Two or more courses of oral systemic corticosteroid use (≥ 3 days each) required in a year or daily maintenance corticosteroid use due to respiratory symptoms
  • Emergency Department visit or Hospital Observation/Admission
  • Emergency Department visit or Hospital Observation/Admission
• Member is a non-smoker ≥1 year; AND
• The requesting physician is a pulmonologist who has completed a bronchial thermoplasty training curriculum and treatment will take place in a facility that is equipped to perform bronchoscopy and to handle respiratory emergencies.
• Note: Authorization is limited to 3 treatment sessions with a recovery period of 3 weeks or longer between sessions. Requests for reauthorization, beyond the initial 3 treatments sessions, are considered experimental/investigational and unproven because the safety and efficacy of repeat procedures is not supported by published peer-reviewed literature.

HPHC Medical Policy HPHC Medical Policy

Bronchial Thermoplasty

Policies are based on medical science and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Exclusions:

The Plan considers bronchial thermoplasty as experimental and investigational for all other indications.

In addition, bronchial thermoplasty is contraindicated for Members with the following conditions:

• The presence of a pacemaker, internal defibrillator, or other implantable electronic device
• Known sensitivity to medications required to perform bronchoscopy, including lidocaine, atropine and benzodiazepines
• No conditions associated with increased risk for adverse events associated with the procedure, such as active respiratory infection, pregnancy, insulin dependent diabetes, epilepsy or other significant comorbidities
• History of life-threatening asthma requiring intubation
• Asthma exacerbation or changing dose of systemic corticosteroids for asthma (up or down) in the past 14 days
• Known coagulopathy condition
• Previously treated prior to full course of bronchial thermoplasty (i.e., no more than 3 treatment sessions)