Medical Policy
Effective Date:
03/01/2013
Title:
Bronchial Thermoplasty
Revision Date:
Document:
BI393:00
CPT Code(s):
31660, 31661
Public Statement
Bronchial thermoplasty is a newly available potential treatment option for patients with severe persistent asthma. It consists of radiofrequency energy delivered to the distal airways with the aim of decreasing smooth muscle mass believed to be associated with airway inflammation. This procedure has not been demonstrated to improve health outcomes in patients with asthma, and is considered by QualChoice to be investigational.
Medical Statement
Bronchial thermoplasty for the treatment of asthma or any other condition is considered investigational as there is a lack of scientific evidence of effectiveness in improving health outcomes. Codes Used in This Policy: 31660 Bronchial thermoplasty one lobe 31661 Bronchial thermoplasty two or more lobes
Limits
Intentially left empty
Reference
Castro M, Rubin AS, Laviolette M et al.(2010) Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med 2010; 181(2):116-24. Centers for Disease Control and Prevention. Asthma fact sheet. Available on-line at http://cdc.gov/nchs/fastats/asthma.htm. Cox G, Thomson NC, Rubin AS et al.(2007) Asthma control during the year after bronchial thermoplasty. N Engl J Med 2007; 356(13):1327-37. FDA Executive Summary. PO80032 Alair Bronchial Thermoplasty System (Asthmatx Incorporated). Anesthesiology and Respiratory Therapy Devices Advisory Panel. October 28, 2009. Available online at 1Hhttp://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/AnesthesiologyandRespiratoryTherapyDevicesPanel/UCM187825. pdf Food and Drug Administration News Release. April 27, 2010. Available online at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm209909.htm National Heart Lung and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). 2007. Available on-line at http://www.nhlbi.nih.gov/guidelines/asthma. Pavord ID, Cox G, Thomson NC et al.(2007) Safety and efficacy of bronchial thermoplasty in symptomatic severe asthma. Am J Respir Crit Care Med 2007; 176(12): 1185-91. Transcript. FDA Anesthesiology and Respiratory Therapy Devices Advisory Panel. October 28, 2009. Available online at 0Hhttp://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/AnesthesiologyandRespiratoryTherapyDevicesPanel/UCM196567. Pdf Thomson NC et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma intervention research (AIR) trial. BMC Pulm Med. 2011; 11:8. Hayes Technology Assessment (2012) Alair Bronchial Thermoplasty System for Treatment of Asthma. Published Dec 28 2012.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.