Alzheimer's Disease denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan of the brain. Alzheimer’s disease is the most common cause of dementia in the elderly, however, other frequently encountered disorders include frontotemporal dementia and dementia with Lewy bodies. It is important to accurately distinguish between these disorders as appropriate treatment depends on the specific diagnosis. Brown and colleagues note that while clinically based testing is useful, the results usually do not enable the clinician to make a definitive diagnosis. The authors report that 18F-labeled fluoro-2-deoxyglucose positron emission tomography (FDG-PET) allows for the detection of neurodegenerative disorders earlier than is otherwise possible.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a metabolic positron emission tomography (PET). The physician reviewer found that few medications are available to treat patients with Alzheimer’s disease. Lecanemab is a medication that targets amyloid, one of the pathologies of Alzheimer’s disease. A thorough evaluation with appropriate studies is needed to support medical therapy for Alzheimer’s disease. Testing can include an amyloid PET scan or cerebrospinal fluid analysis. In this patient’s clinical setting, there is adequate support for the requested metabolic PET scan. The patient’s recent blood test showed that the patient’s cognitive issues could be consistent with the early stages of Alzheimer’s disease.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hospice care services. The records provided for review suggest that this patient is at an elevated risk of mortality. However, the patient’s condition lacks the markers of expected mortality within the next six months to support an indication for the requested hospice care services. There are challenges to predicting six-month mortality in Alzheimer’s patients. One key factor is nutrition and hydration. The patient is maintaining her nutrition and hydration as she is eating 50-75% of her meals. In addition, the patient does not have pressure wounds, aspiration pneumonia, kidney failure, or other major co-morbidities associated with six-month mortality in patients with advanced dementia. The patient’s diagnosis of myasthenia gravis is not a determining factor in her need for hospice care.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing (CPT 83520) provided by Athena Diagnostics, Inc. Findings: The physician reviewer found that evaluating data on the current status of biomarkers for Alzheimer’s disease, Blennow and colleagues report that while a large number of clinical studies very consistently show that these biomarkers contribute with diagnostically relevant information, also in the early disease stages, future studies are warranted to validate these promising results further. In this case, the patient presented with complaints related to memory deficits. While the use of biomarker testing may be helpful, their results have not been demonstrated to be diagnostic, as diagnosis of cognitive disorders remain based on clinical evaluations including a patient’s history and neuropsychological studies.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving alzheimer's disease, then check the rights and deadlines that apply to your plan.