Blood denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 44-year-old male originally diagnosed with Stage IVB Hodgkin’s Disease in 1975 treated with C-MOP chemotherapy and a single fraction of thoracic radiation. He next presented in June 2004 with an abnormal chest X-ray showing a spiculated 1.4cm nodule in the right upper lobe. Ultimately he underwent resection of an invasive non-small cell lung cancer and per the record, he had a 1.7cm lung tumor resected with pleural invasion but no nodal involvement He received no adjuvant therapy for what appears to have been a Stage I lung cancer. Within the same timeframe he was noted to have a progressive thrombocytopenia and was subsequently diagnosed with myelodysplastic syndrome (MDS).

Physician 1The patient is a 57-year-old male with well-controlled HIV who is on highly active antiretroviral therapy. The patient has acute myeloid leukemia (AML) and possible antecedent MDS. He is now being considered for consolidation of first remission with a peripheral stem cell transplant. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is considered experimental.Further data regarding this patient’s AML, AHD, and cytogenetics is needed to help define where he falls in the National Comprehensive Cancer Network guidelines. The decision to pursue treatment should rest on those data and not on his HIV positivity. As such, cytogenetic results and additional hematologic data should be obtained. Unless the patient’s HIV is poorly controlled, his HIV status does not preclude stem cell transplantation.

Where the denial was upheld

Physician 1: The patient was diagnosed with chronic lymphocytic leukemia (CLL) in 2000. He was initially treated with chemotherapy and immunotherapy. A bone marrow biopsy in June 2005 revealed relapse of the CLL as well as myelodysplasia. It was recommended that he undergo bone marrow transplantation but no HLA-identical match, either related or unrelated could be found. The patient then went to Israel and received a haploidentical graft from his daughter. The patient died in October 2005.At issue is whether haploidentical stem cell transplantation was likely to be more beneficial for the patient than any available standard therapy.The standard transplant for myelodysplasia is an allogeneic transplant with HLA-identical stem cells, either from a relative or an unrelated donor. Unfortunately, no such match can be found in many patients, as was the case here.

An enrollee has requested reimbursement for the Autonomic Nervous Function Testing - autonomic reflex screen (CPT 95924) and Endopat study (CPT 95923). The autonomic nervous system is responsible for various functions including heart rate, body temperature, breathing, digestion, and sensation. The autonomic nervous system is composed of the sympathetic and parasympathetic nervous systems and their interplay. Disease occurs when there is the parasympathetic and sympathetic are unbalance or when there is direct damage to the autonomic nervous system in various disease states. Some symptoms linked to autonomic nervous system disease is dizziness, sweating abnormalities, and loss of appetite.

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