Anoxic Brain Injury denials in California external review

What the reviewers wrote

Where the denial was overturned

A 26-year-old male enrollee requested immediate neuropsychiatry assessment to determine whether his behavior is attributable to his brain injury, psychiatric condition or combination of both; an assessment to make a differential diagnosis of his brain condition and psychiatric condition; learning and coping skills so he can have a productive life; an assessment of his psychological defects and his psychiatric/psychological condition; and intensive individual psychiatric therapy (not group therapy) with cognitive behavioral dialectical therapy, with any other therapies a neuropsychiatrist can provide for medical evaluation of his late effects of anoxic brain injury. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for the following inpatient neuro-rehabilitation treatment program services: physical therapy, occupational therapy, speech therapy, educational therapy, counseling, nursing, behavior management, clinical case management and family counseling and education. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient is likely to benefit from a facility dedicated to neuro-rehabilitation. Per the records, he is displaying symptoms that are behavioral as well as cognitive secondary to anoxic brain injury from carbon monoxide poisoning. Neuro-rehabilitation programs typically have a team-based approach to treating neurobehavioral problems.

Where the denial was upheld

Physician 1: The patient is a 27-year-old female who experienced ischemic brain injury and coma after a heart transplant for cardiomyopathy. She has received hyperbaric oxygen therapy for her brain injury/palsy and her family and provider consider the treatment beneficial. The Health Plan deemed the therapy experimental/investigational and reimbursement and future coverage were denied.A search of the relevant medical literature revealed no studies to suggest a benefit from hyperbaric oxygen for persistent deficits related to toxic, ischemic or anoxic encephalopathy. Additionally, the peer-reviewed literature does not demonstrate evidence suggesting efficacy of hyperbaric oxygen in patients following coma. Therefore, I have determined that the requested therapy was/is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continuous electroencephalography (EEG) monitoring at a tertiary level facility, a brain magnetic resonance imaging (MRI) while the patient is ventilated at a tertiary facility, and treatment at a tertiary level facility.At issue is whether continuous EEG monitoring is medically necessary to treat the patient’s condition. If so, is it medically necessary to be performed at a tertiary level facility? Additionally, is a brain MRI while the patient is ventilated medically necessary to treat the patient’s condition. If so, is it medically necessary to be performed at a tertiary level facility? Is treatment at a tertiary level facility medically necessary to treat the patient’s medical condition?Anoxic brain injury is most often associated with clinical events such as cardiac arrest.

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 anoxic brain injury, then check the rights and deadlines that apply to your plan.