Payer coverage for bronchial thermoplasty: shifting the traditional paradigm for refractory asthma therapy

Bronchial thermoplasty: State of the art

Since the publication of a sham-controlled, randomized trial (AIR2) and subsequent marketing approval by the US Food and Drug Administration, we have significantly advanced our understanding of bronchial thermoplasty (BT)'s scientific basis, long-term safety, clinical efficacy and cost-effectiveness. In particular, the last 2 years have witnessed multiple research publications on several of these counts. In this review, we critically appraise our evolving understanding of BT's biologic underpinnings and clinical impact, offer an evidence-based patient workflow guide for the busy pulmonologist and highlight both current challenges as well as potential solutions for the researcher and the clinician.

Transvenous Phrenic Nerve Stimulation for Central Sleep Apnea: Clinical and Billing Review

Central sleep apnea (CSA) frequently coexists with heart failure and atrial fibrillation and contributes to cardiovascular disease progression and mortality. A transvenous phrenic nerve stimulation (TPNS) system has been approved for the first time by the Food and Drug Administration for the treatment of CSA. This system, remedē® ZOLL Medical, Inc. is implanted during a minimally invasive outpatient procedure, and has shown a favorable safety and efficacy profile. Currently, patients' access to this therapy remains limited by the small number of specialized centers in the US and the absence of a standard coverage process by insurers. While a period of evaluation by insurers is expected for new therapies in their early stages, the impact on patients is particularly severe given the already limited treatment options for CSA. Implantation and management of this novel therapy requires the establishment of a specialized multidisciplinary program as part of a Sleep Medicine practice and support from health care systems and hospitals. Several centers in the US have been successful in building sustainable TPNS program offering this novel therapy to their patients by navigating the current reimbursement environment. In this article, we will review the background and efficacy data of TPNS and briefly address relevant aspects of the clinical activities involved in a TPNS program. The article will present the status of coverage and reimbursement for this novel therapy. We will also discuss the current approach to obtaining reimbursement from third party payors during this transitional period of evaluation by Medicare and other insurers.

Advanced Diagnostic and Therapeutic Bronchoscopy: Technology and Reimbursement

Advanced interventional pulmonary procedures of the airways, pleural space, and mediastinum continue to evolve and be refined. Health care, finance, and clinical professionals are challenged by both the indications and related coding complexities. As the scope of interventional pulmonary procedures expands with advanced technique and medical innovation, program planning and ongoing collaboration among clinicians, finance executives, and reimbursement experts are key elements for success. We describe advanced bronchoscopic procedures, appropriate Current Procedural Terminology coding, valuations, and necessary modifiers to fill the knowledge gap between basic and advanced procedural coding. Our approach is to balance the description of procedures with the associated coding in a way that is of use to the proceduralist, the coding specialist, and other nonclinical professionals.

Bronchial Thermoplasty

Bronchial thermoplasty is an advanced therapy for severe asthma. It is a bronchoscopic procedure in which radiofrequency energy is applied to the airway wall, resulting in decreased airway smooth muscle burden. Human trials have shown that bronchial thermoplasty may reduce asthma exacerbations and improve quality of life in patients with severe uncontrolled asthma. It has been demonstrated to be a safe procedure, with most adverse events being early and mild. More studies are required to understand the precise effects of bronchial thermoplasty on the asthmatic airway and optimal parameters to appropriately select patients for this novel procedure.

Innovative treatments for severe refractory asthma: how to choose the right option for the right patient?

The increasing understanding of the molecular biology and the etiopathogenetic mechanisms of asthma helps in identification of numerous phenotypes and endotypes, particularly for severe refractory asthma. For a decade, the only available biologic therapy that met the unmet needs of a specific group of patients with severe uncontrolled allergic asthma has been omalizumab. Recently, new biologic therapies with different mechanisms of action and targets have been approved for marketing, such as mepolizumab. Other promising drugs will be available in the coming years, such as reslizumab, benralizumab, dupilumab and lebrikizumab. Moreover, since 2010, bronchial thermoplasty has been successfully introduced for a limited number of patients. This is a nonpharmacologic endoscopic procedure which is considered a promising therapy, even though several aspects still need to be clarified. Despite the increasing availability of new therapies, one of the major problems of each treatment is still the identification of the most suitable patients. This sudden abundance of therapeutic options, sometimes partially overlapping with each other, increases the importance to identify new biomarkers useful to guide the clinician in selecting the most appropriate patients and treatments, without forgetting the drug-economic aspects seen in elevated direct cost of new therapies. The aim of this review is, therefore, to update the clinician on the state of the art of therapies available for refractory asthma and, above all, to give useful directions that will help understand the different choices that sometimes partially overlap and to dispel the possible doubts that still exist.