Want to start FeNO testing? Here is what you need to know

FeNO (fractional exhaled nitric oxide) testing is a simple, quick, and non-invasive test of airway inflammation, available at the point-of-care for asthma.(1,2) FeNO testing is reimbursed by most national and regional ?insurers?, ?and is recommended for the diagnosis and/or management of asthma patients.?(2-4) ?This article tells you everything you need to know about starting FeNO testing in your clinic.

Asthma in the USA

Globally, around 300 million people suffer with asthma.(5) It is highly prevalent in the US, with around 27 million sufferers – this is approximately 1 in every 12 people.(6)

In the USA, there are around 10 deaths every day from asthma-related causes.(6,7) Worldwide, this totals 1,000 deaths a day, and it is estimated that two thirds of these are preventable.(8,9)

Not only is the prevalence and mortality rates of asthma high, but it also costs the USA around $81.9 billion a year – 61% of these costs being medical.(10) It is estimated that 75% of costs associated with asthma may be due to poor disease control.(11)

FeNO could help to improve the lives of those suffering with asthma and could potentially contribute to reducing costs through better asthma management.(12-15)

What is FeNO?

FeNO stands for fractional exhaled nitric oxide and is an objective measurement of the level of inflammation in a patient’s airways.(2) Levels of airway inflammation are higher in patients with Type 2 asthma, so FeNO testing gives an insight into the patient’s condition.(2)

FeNO testing is the only point-of-care, non-invasive test which directly measures airway inflammation.(2,16) It simply involves breathing through the breathing handle at about the same pressure as blowing bubbles into a drink through a straw.

But why is this useful?

Asthma is characterised by chronic inflammation, yet other asthma diagnostics tests do not directly test for this.(16,17) FeNO testing can help you complete the picture of a patient’s diagnosis.(16) Some patients may not be aware that they have asthma, especially if their symptoms aren’t severe.(18)

FeNO testing is an incredibly valuable tool, not only can it aid in asthma diagnosis, but it can help manage and monitor the disease too.(1,19,20) FeNO is highly sensitive to inhaled corticosteroids, so it gives you an insight into whether a patient’s medication is working, if they are adherent, and help you personalize treatment options.(16,21,22) This can involve stepping up or stepping down dosage of ICS (inhaled corticosteroids), or guide biologics treatment, thereby reducing costs.(16,23)

Asthma is 7x more likely with a FeNO above 40 parts per billion (ppb).(24) FeNO-guided asthma management can help reduce the chance of exacerbations by up to 50% in both adults and children,? which in turn can help reduce hospital admissions and improve patient quality of life.(25-27)

Reimbursement

FeNO testing is reimbursed throughout the United States with approximately 84% of all insured lives covered.(28) This rises to as high as 98% in Indiana, 97% in California, and 89% in Texas.(3)

As of March 2024, over 279 ?million Americans have access to FeNO testing, including those on Medicaid and Medicare.(28)

In 2018, major insurance company, Aetna updated their clinical policy to include FeNO, which gave their 22 million medical members and 1.2 million healthcare professionals access to FeNO testing.(4) They deem it ‘medically necessary’ for asthma patients “for evaluation of asthma and for monitoring response to long-term control therapy in members aged 7 years and older.”(4)

In 2023, Blue Cross Blue Shield’s largest single state plan,?Blue Cross Blue Shield of Michigan?(~5 million lives covered) followed suit with a switch to positive.(29)

Some insurance providers do not have a specific FeNO policy and are listed as ‘Silent’. For FeNO testing, often the payer requirement is simply that the FeNO test is for a diagnosis and/or management of asthma only and that the HCP deems FeNO testing medically necessary. Claims are typically approved for coverage, but this is not guaranteed.

Check out our reimbursement page which has a handy interactive map to show you what coverage looks like in your state, and a reimbursement calculator to determine your annual reimbursement for implementing FeNO testing.

The device of choice, NIOX VERO?(30)

The NIOX VERO? is the gold standard FeNO testing device, and the only FDA approved device that removes environmental nitric oxide, which can typically exist in the range of 3 – 500 ppb, ensuring an accurate FeNO measurement.(30-32) The NIOX VERO? is also the only device which fully conforms to ATS and ERS guidelines for FeNO testing.(30,33)

Join the thousands of healthcare professionals who are already FeNO testing with NIOX?, make a difference for your asthma patients, and cut costs associated with asthma.(16,23,34)

Interested? Request a demo, or learn more about FeNO in practice on our FeNO Learn app, which includes a course dedicated to the basics of FeNO, and webinars from global leaders in FeNO.

References:

1.???????? Ali H et al. The Potential of Fractional Exhaled Nitric Oxide as a Biomarker in Predicting and Optimizing Use of Treatment in Asthma. South East European Journal of Immunology. 2023;6(1):18-23.

2.???????? Alving K et al. Validation of a new portable exhaled nitric oxide analyzer, NIOX VERO?: randomized studies in asthma. Pulm Ther. 2017;3:207-218.

3.???????? Policy Reporter. Available at; https://www.policyreporter.com/. Accessed; Jun 2024

4.???????? Aetna. Exhaled breath tests. Available at: https://www.aetna.com/cpb/medical/data/600_699/0691.html. Accessed; Jun 2024

5.???????? Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2024. Available at; https://ginasthma.org/2024-report/. Accessed; Jun 2024

6.???????? Asthma and Allergy Foundation of America (AAFA). Asthma Facts. Available at; https://aafa.org/asthma/asthma-facts/. Accessed; Jun 2024

7.???????? Centers for Disease Control and Prevention. (2023). Most Recent National Asthma Data, Mortality. U.S. Department of Health and Human Services. Available at:?https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm. Accessed on: Jun 2024

8.???????? Global Asthma Network. The Global Asthma Report. 2022.

9.???????? Royal College of Physicians (RCP). Why asthma still kills: the National Review of Asthma Deaths (NRAD). 2014.

10.?? Nurmagambetov T et al. The Economic Burden of Asthma in the United States, 2008-2013. American Thoracic Society. 2017

11.?? Apter AJ. Enhancing patients adherence to asthma therapy. Up to Date. Last updated; September 2022. Available at; https://www.uptodate.com/contents/enhancing-patient-adherence-to-asthma-therapy.

12.?? Asthma and Lung. Investing in Breath: Measuring the economic cost of asthma and COPD in the UK and identifying ways to reduce it through better diagnosis and care. Technical report (2023)

13.?? Brooks EA, et al. Cost-effectiveness of fractional exhaled nitric oxide (FeNO) measurement in predicting response to omalizumab in asthma ClinicoEconomics and Outcomes Research. 2019;Volume 11:301–7.

14.?? Buendía JA et al. Cost utility of fractional exhaled nitric oxide monitoring for the management of children asthma. Cost Effectiveness and Resource Allocation. 2021 3;19(1):33.

15.?? Barry LE et al. Cost-Effectiveness of Fractional Exhaled Nitric Oxide Suppression Testing as an Adherence Screening Tool Among Patients With Difficult-to-Control Asthma. The Journal of Allergy and Clinical Immunology: In Practice. 2023.

16.?? Loewenthal L et al. FeNO in asthma. Semin Respir Crit Care Med. 2022;43:635-645

17.?? Hanania NA et al. Measurement of fractional exhaled nitric oxide in real-world clinical practice alters asthma treatment decisions. Ann Allergy Asthma Immunol. 2018;120(4):414-418.

18.?? American College of Allergy, Asthma, and Immunology. Asthma Symptoms. Available at; https://acaai.org/asthma/symptoms/

19.?? Czubaj-Kowal M et al. Relationship between air pollution and the concentration of nitric oxide in the exhaled air (feno) in 8–9-year-old school children in Krakow. International Journal of Environmental Research and Public Health. 2021;18(13):6690.

20.?? Heaney LG et al. Medical Research Council UK Refractory Asthma Stratification Programme (RASP-UK). Remotely monitored therapy and nitric oxide suppression identifies nonadherence in severe asthma. Am J Respir Crit Care Med. 2019;199(4):454-464.

21.?? Louis R et al. European Respiratory Society guidelines for the diagnosis of asthma in adults. European Respiratory Journal. 2022;60(3).

22.?? Pianigiani T et al. Exploring the interaction between fractional exhaled nitric oxide and biologic treatment in severe asthma: A systematic review. Antioxidants. 2023;12(2):400.

23.?? Porsbjerg C et al. Asthma. The Lancet. 2023.

24.?? Wang Z et al. Agency for Healthcare Research and Quality (AHRQ). The clinical utility of fractional exhaled nitric oxide (FeNO) in asthma management. Comparative Effectiveness Reviews, 197. 2017.

25.?? Petsky HL et al. Tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils): a systematic review and meta-analysis. Thorax. 2018;73(12):1110-9.

26.?? Petsky HL et al. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane Database Syst Rev. 2016;9(9):CD011440.

27.?? NHS England. Fractional Exhaled Nitric Oxide (FeNO). Available at; https://www.england.nhs.uk/aac/what-we-do/innovation-for-healthcare-inequalities-programme/rapid-uptake-products/fractional-exhaled-nitric-oxide/.

28.?? NIOX?. Data on File; MKT-DOF-009

29.?? Blue Cross Blue Shield Blue Care Network Medical Policy. Exhaled nitric oxide and exhaled breath condensate in the diagnosis and management of respiratory disorders. Available at; https://www.bcbsm.com/amslibs/content/dam/public/mpr/mprsearch/pdf/87127.pdf. Accessed; Jun 2024.

30.?? NIOX?. Data on file; MKT-DOF-007. 2023

31.?? Clapp L et al. Analysis of the relationship between ambient levels of O3, NO2 and NO as a function of NOx in the UK. Atmos Environ. 2001;35(36):6391-6405

32.?? NIOX?. NIOX VERO Stability Summary Report. 2018.

33.?? American Thoracic Society; European Respiratory Society. ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005. Am J Respir Crit Care Med. 2005;171(8):912-30.

34.?? NIOX?. Data on file; MKT-DOF-013. 2024

MKT-PRM-US-0118