Diagnosis: Respiratory System-Other-Bilateral Lung Transplant
Treatment: Diagnostic Testing-Respiratory Viral Panel
The health plan denied the Respiratory Viral panel as not medically necessary.
The reviewer has overturned in whole the health plan's determination.

This patient has a bilateral lung transplant for cystic fibrosis (CF) complicated by bronchiolitis obliterans, hypertension (HTN), diabetes mellitus type 2 (DM2), chronic kidney disease (CKD), and basal cell cancer, who was undergoing bronchoscopy for surveillance in the setting of an asymptomatic worsening of pulmonary function test (PFT) values. Post-procedure chest x-ray (CXR) found a new, hazy left lower lobe (LLL) airspace opacity. A bronchoalveolar lavage (BAL) culture ultimately grew Pseudomonas, and levofloxacin was started.

The Infectious Agent Detection by Nucleic Acid (deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)), Respiratory Virus Panel was medically necessary. He had worsening lung function without explanation. Society guidelines and standard of care documents would suggest using viral polymerase chain reaction (PCR) to help establish a diagnosis. Most documents suggest looking for a broad variety of viruses, with many listing at least 7-8 different varieties as a minimum number of varieties. Some studies used panels that looked at up to 19 viruses. Associations have been found between viral infection and acute rejection, and therapies are available for some of these infections. As such, a broader panel such as the one used in this case, was both medically necessary and supported by the literature as well as recommended within cited society guidelines and expert authors from UpToDate.

The patient had worsening PFTs, concerning for rejection. Guidelines would suggest evaluating for a variety of infections, including viral infections and that a broader based diagnostic approach with viral PCR is recommended. This would be required for diagnosis and to guide treatment. The cited guidelines below recommend a broad based viral assay, making this part of generally accepted standard of care. Such testing would be clinically appropriate, would not be for the patient's convenience, and obtaining this testing would not influence the setting.