Anemia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for monitored anesthesia care performed during a diagnostic colonoscopy and diagnostic esophagogastroduodenoscopy. The medical literature establishes that monitored anesthesia care (MAC) plays a significant role in facilitating the effective completion of a colonoscopy and upper endoscopy. MAC services involve the administration of intravenous sedation and analgesia to ensure patient comfort and cooperation during the procedure. Medical literature notes that anesthesia provider assistance should be considered during a gastrointestinal (GI) endoscopy for prolonged or therapeutic endoscopic procedures requiring deep sedation. In this case, the patient was scheduled for a colonoscopy.

A 45-year-old female enrollee has requested Procrit injections for treatment of her anemia. Findings: The physician reviewer found that Procrit is indicated for use in anemic patients undergoing elective surgery who are at risk of blood loss. Medical indications supporting the use of Procrit include having a hemoglobin level greater than 10, but less than or equal to 13. This patient met these criteria. Procrit helps stimulate the bone marrow’s ability to produce red blood cells. By increasing the red blood cell supply before surgery, the hemoglobin level is increased and remains higher during and after surgery. The goal is to reduce the number of blood transfusions during and after certain major surgeries. Studies have shown that when Procrit is given before surgery, patients produce additional red blood cells and have a significant increase in hemoglobin by the day of surgery.

Where the denial was upheld

A 43-year-old female enrollee has requested reimbursement for hysterectomy services provided in Lima, Peru. The Health Plan has denied this request indicating the services at issue were not required on an urgent basis. Findings: The physician reviewer found that this case involves a female patient with a history of uterine fibroid, menometrorrhagia and anemia. The patient presented to her provider with complaint of menometrorrhagia with two days of heavy bleeding and clotting. The provider noted the patient had been seen by her gynecologist who recommended either ablation or hysterectomy secondary to fibroid uterus. The patient subsequently traveled to Peru. Prior to her leaving for Peru, her physician increased her iron and recommended she have additional labs performed when she returned.

An enrollee has requested authorization and coverage for hemoglobin meter for home use. This patient’s records document hematologic complications of pancytopenia, which is likely a major component of her lupus exacerbation. Adequate monitoring involves more than just hemoglobin monitoring. Researchers noted that as progressive anemia can be multifactorial in lupus, disease activity monitoring should involve more than just hemoglobin monitoring. The authors discussed that the current standard of care for lupus monitoring include full blood count, serum creatinine and albumin, C-reactive protein, and estimated glomerular filtration rate (eGFR). There is a paucity of data in the medical literature demonstrating that home monitoring of this patient’s hemoglobin will be more effective in managing her condition than standard of care recommendations.

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 anemia, then check the rights and deadlines that apply to your plan.