Aneurysm: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter permanent occlusion or embolization, with flow diversion.Findings: Three physician reviewers found that there is support for the requested services in this patient’s case. In the medical literature, 44 small (less than 10 mm) aneurysms of the internal carotid artery were treated with flow diversion. There was one major complication of intraprocedural rupture. The authors concluded that flow diversion is a safe treatment alternative for small internal carotid artery aneurysms. In an additional study, the safety and efficacy of flow diversion treatment for 100 consecutive patients with small (less than or equal to 7 mm) aneurysms was reported.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for endovascular stent repair procedure with a one-day inpatient stay.According to researchers, “Complex AAAs have traditionally been treated with an open surgical repair (OSR). During the past decade, fenestrated endovascular aneurysm repair (FEVAR) has emerged as a viable option.” The authors found, “FEVAR was associated with lower perioperative morbidity and mortality compared with OSR for the management of complex AAAs.” Moreover, researchers also found that with OSR, “the odds for major complications, minor complications, and short-term mortality were significantly higher compared with complex endovascular aneurysm repair.”In this case, the patient has a large AAA at risk for rupture. Based on the CTA report, the AAA was 6 centimeters in diameter.

Where the denial was upheld

A 29-year-old male enrollee has requested coverage for acupuncture services for treatment of his shoulder, arm, leg and entire back pain. Findings: The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. According to the documentation submitted for review, the patient has had an unknown number acupuncture sessions for the treatment of his condition. The medical records fail to document a pre-care baseline in order to assess the benefits of an acupuncture trial. In addition, there are no measurable, objective symptoms, functional deficits improvements documented in order to support the medical necessity of the acupuncture services.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgical aortic aneurysm repair for treatment of her ascending thoracic aortic aneurysm. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. If surgery is done, it would require replacement of the ascending aorta, which is a procedure with definite risks, including bleeding, infection, stroke, myocardial infarction and multi-organ failure. Surgery for ascending aortic aneurysms are not undertaken unless the aneurysm measures over 5.0 cm, or there are other compelling reasons, such as rapid expansion, concomitant aortic dissection or Marfan’s features. None of these are present in this patient’s case. The mainstay of treatment in patients with 4.0 cm ascending aortic aneurysms is surveillance.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for aneurysm was denied, the published record says the denial is worth fighting.